General Principles of Fracture Care Treatment & Management

Updated: Jan 25, 2016
  • Author: Richard Buckley, MD, FRCSC; Chief Editor: Jason H Calhoun, MD, FACS  more...
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Approach Considerations

Fracture management can be divided into nonoperative and operative techniques. The nonoperative approach consists of a closed reduction if required, followed by a period of immobilization with casting or splinting. Closed reduction is needed if the fracture is significantly displaced or angulated. [38] Pediatric fractures are generally much more tolerant of nonoperative management, owing to their significant remodeling potential. [39]

If closed reduction is inadequate, surgical intervention may be required. Indications for surgical intervention include the following:

  • Failed nonoperative (closed) management
  • Unstable fractures that cannot be adequately maintained in a reduced position
  • Displaced intra-articular fractures (>2 mm)
  • Patients with fractures that are known to heal poorly following nonoperative management (eg, femoral neck fractures) [40]
  • Large avulsion fractures that disrupt the muscle-tendon or ligamentous function of an affected joint (eg, patella fracture)
  • Impending pathologic fractures
  • Multiple traumatic injuries with fractures involving the pelvis, femur, or vertebrae
  • Unstable open fractures, any type II or type III open fracture
  • Fractures in individuals who would poorly tolerate prolonged immobilization required for nonoperative management (eg, elderly patients with proximal femur fractures [41] )
  • Fractures in growth areas in skeletally immature individuals that have increased risk for growth arrest (eg, Salter-Harris types III-V)
  • Nonunions or malunions that have failed to respond to nonoperative treatment

Contraindications to surgical reconstruction are as follows:

  • Active infection (local or systemic) or osteomyelitis
  • Soft tissues that compromise the overlying fracture or the surgical approach because of poor soft-tissue quality due to soft-tissue injury or burns, excessive swelling, previous surgical scars, or active infection
  • Medical conditions that contraindicate surgery or anesthesia (eg, recent myocardial infarction)
  • Cases in which amputation, rather than attempted fracture fixation, would better serve the limb and the patient

Elements of Initial Fracture Management

The most important factors in fracture healing are blood supply and soft-tissue health, and initial management of an injured limb should have the goal of maintaining or improving these. [23]

The initial management of fractures consists of realignment of the broken limb segment (if grossly deformed) and then immobilizing the fractured extremity in a splint. The distal neurologic and vascular status must be clinically assessed and documented before and after realignment and splinting. If a patient sustains an open fracture, achieving hemostasis as rapidly as possible at the injury site is essential; this can be achieved by placing a sterile pressure dressing over the injury site (see Open Fractures).

Splinting is critical in providing symptomatic relief for the patient, as well as in preventing potential neurologic and vascular injury and further injury to the local soft tissues. Patients should receive adequate analgesics in the form of acetaminophen or opiates, if necessary.

Open fractures

The treatment goals for open fractures are as follows:

  • To prevent infection
  • To allow the fracture to heal
  • To restore function in the injured limb

Once the initial assessment, evaluation, and management of any life-threatening injury are completed, the open fracture is treated. Hemostasis should be obtained if there is significant ongoing bleeding, though bone bleeding is best reduced by anatomic reduction. Gross contaminants can be removed if possible and the soft-tissue wound can be covered by a sterile dressing moistened with normal saline. Harsher adjuncts, such as iodine solutions, are not recommended, because of their cytotoxic effects. [42] Tetanus immunization should be provided if the patient does not have current immunity.

Bhandari’s Evidence-Based Orthopedics [42] provides an excellent overview of current best evidence for open fracture management. Time to antibiotic administration has been shown to be the most important factor in reduction of infection risk in open fractures; therefore, antibiotics should be given immediately.

For type I and type II fracture injuries, a first-generation cephalosporin (eg, cefazolin) is adequate. If the wound is severely contaminated (type III), an aminoglycoside (eg, gentamicin, tobramycin) is commonly added to complement treatment. If the injury is a "barnyard injury" (contaminated with soil) or water-type injury, penicillin may also be added to provide prophylaxis against Clostridium perfringens and other anaerobes.

Rodriguez et al reported on the use of an evidence-based antibiotic protocol based on open fracture grade, in which patients with grade I or II fractures received cefazolin (clindamycin in the case of allergy) and those with grade III fractures received ceftriaxone (clindamycin and aztreonam in the case of allergy) for 48 hours; aminoglycosides, vancomycin, and penicillin were excluded from the protocol. [43] Implementation of this protocol for open fracture antibiotic prophylaxis led to significantly reduced use of aminoglycoside and glycopeptide antibiotics without increasing rates of in skin and soft-tissue infection.

Prophylactic use of quinolones is not appropriate, both because of the rapid development of resistant staphylococci and because quinolones are important drugs in the treatment of implant-related infections. [44]

There is little evidence available to guide the decision of appropriate duration to continue antibiotic administration, but general practice in North America is to provide 24 hours of coverage after definitive wound closure.

The traditional teaching of open fracture management was that urgent irrigation and debridement (I&D) of the wound in the operating room (OR) is mandatory within 6 hours and that open fractures are considered orthopedic emergencies. More recent data, such as the findings from the Lower Extremity Assessment Program (LEAP), suggested that surgical I&D within 24 hours of injury is sufficient. [42] For type II and type III injuries, serial I&Ds are recommended every 24-48 hours after the initial debridement until a clean surgical wound is ensured and no necrotic tissue persists.

There is some controversy with regard to the most appropriate type of irrigation fluid, volume, and type of pressure. A balance is required between antisepsis and cytotoxicity of the native tissues. Bhandari et al advocated the use of simple normal saline for irrigation via a low-pressure delivery system. [42] A widely accepted approach is to use a minimum of 3 L of irrigation for a type I fracture, 6 L for a type II fracture, and 9 L for a type III fracture.

The wound is closed when it is clean, ideally within 3-7 days of the initial injury; the risk of infection and flap failure rise precipitously when closure of type III fractures occurs more than 7 days after injury. [42] Plastic surgery colleagues may need to be involved in the wound closure.

Management of the open fracture depends on the site of injury and type of open fracture. The wound is subsequently stabilized either temporarily or definitively. If soft-tissue coverage over the injury is inadequate between debridements, wet-to-dry dressings or negative-pressure wound therapy (eg, vacuum-assisted closure [VAC] dressings) may be used. If the fracture reduction cannot be maintained between debridements, an external fixator can be used with the pin sites well outside the zone of injury. [7]


Nonoperative Therapy

Early fracture management is generally aimed at controlling hemorrhage, providing pain relief, preventing ischemia-reperfusion injury, and removing potential sources of contamination (foreign body and nonviable tissues). Once these tasks are accomplished, the fracture should be reduced and the reduction should be maintained, which will optimize the conditions for fracture union and minimize potential complications.

The ultimate goal of fracture management is to ensure that the involved limb segment, when healed, has returned to its maximal possible function. This is accomplished by obtaining and subsequently maintaining a reduction of the fracture with an immobilization technique that allows the fracture to heal and, at the same time, provides the patient with functional aftercare. Either nonoperative or surgical means may be employed.

Nonoperative (closed) therapy consists of casting and traction (skin and skeletal traction).


Closed reduction should be performed initially for any fracture that is displaced, shortened, or angulated. This is achieved by applying traction to the long axis of the injured limb, reversing the mechanism of injury/fracture, and finally immobilizing the limb through casting or splinting. Splints and casts can be made from fiberglass or plaster of Paris. Barriers to accomplishing reduction include soft-tissue interposition at the fracture site and hematoma formation that create tension in the soft tissues.

Closed reduction is contraindicated in the following circumstances [14] :

  • If there is no displacement
  • If displacement exists but is not relevant to functional outcome (eg, humeral shaft fracture where the shoulder and elbow motion can compensate for residual angulation)
  • If reduction is impossible (severely comminuted fracture)
  • If the reduction, when achieved, cannot be maintained
  • If the fracture has been produced by traction forces (eg, displaced patellar fracture)


For hundreds of years, traction has been used for the management of fractures and dislocations that cannot be treated by means of casting. With the advancement of orthopedic implant technology and operative techniques, traction is rarely used for definitive fracture/dislocation management. Two types of traction exist: skin traction and skeletal traction.

Skin traction

In skin traction, traction tapes are attached to the skin of the limb segment that is below the fracture or a foam boot is securely fitted to the patient's foot. In the application of skin traction, or Buck traction, usually 10% of the patient's body weight (up to a maximum of 10 lb) is recommended. [39] At weights greater than 10 lb, superficial skin layers are disrupted and irritated. Because most of the forces created by skin traction are lost and dissipated in the soft-tissue structures, skin traction is rarely used as definitive therapy in adults; rather, it is commonly used as a temporary measure until definitive therapy is achieved.

Skeletal traction

In skeletal traction, a pin (eg, a Steinmann pin) is placed through a bone distal to the fracture. Weights are applied to this pin, and the patient is placed in an apparatus to facilitate traction and nursing care. Skeletal traction is most commonly used in femur fractures: A pin is placed in the distal femur (see the image below) or proximal tibia 1-2 cm posterior to the tibial tuberosity. Once the pin is placed, a Thomas splint is used to achieve balanced suspension.

Femur fracture managed with skeletal traction and Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur.

Surgical Therapy

The four AO (Arbeitsgemeinschaft für Osteosynthesefragen [Association for Osteosynthesis]) principles, in their basic form, have governed the society’s approach to fracture management for decades. [7] They are as follows:

  • Anatomic reduction of the fracture fragments - For the diaphysis, anatomic alignment ensuring that length, angulation, and rotation are corrected as required; intra-articular fractures demand anatomic reduction of all fragments
  • Stable fixation, absolute or relative, to fulfill biomechanical demands
  • Preservation of blood supply to the injured area of the extremity and respect for the soft tissues
  • Early range of motion (ROM) and rehabilitation

Preparation for operative intervention

Detecting and adequately addressing all other injuries, including comorbidities and preexisting medical conditions, is essential. If patients have multiple medical problems, consult an internal medicine specialist and/or anesthesiologist before performing any operative intervention.

Prophylactic antibiotics (cefazolin, 1-2 g) should be administered prior to incision. If the patient is allergic to penicillin, clindamycin can be administered. Patients with open fractures should be given appropriate antibiotic prophylaxis (see Elements of Initial Fracture Management). There is no evidence to support continuing prophylactic antibiotics beyond 24 hours postoperatively. [42]

Open reduction and internal fixation

The objectives of open reduction and internal fixation (ORIF) include the following:

  • Adequately exposing the fracture site
  • Minimizing soft-tissue stripping
  • Obtaining a reduction of the fracture
  • Stabilizing and maintaining the reduction that has been achieved

Kirschner wires

Kirschner wires (K-wires) are commonly used for temporary and definitive treatment of fractures. However, K-wires resist only changes in alignment; they do not resist rotation, and they have poor resistance to torque and bending forces. K-wires are commonly used as adjunctive fixation for screws or plates and screws that involve fractures around joints.

When K-wires are used as the sole form of fixation, they are supplemented by casting or splinting. The wires can be placed percutaneously or through a miniopen mechanism. As stated by Canale, K-wire fixation "is adequate for small fragments in metaphyseal and epiphyseal regions, especially in fractures of the distal foot, wrist, and hand, such as Colles fractures, and in displaced metacarpal and phalangeal fractures after closed reduction." [23] K-wires are also commonly used as adjunctive therapy for many fractures, including patellar fractures, proximal humerus fractures, olecranon fractures, and calcaneus fractures.

Plates and screws

Plates and screws are commonly used in the management of articular fractures. This use demands an anatomic reduction of the fracture fragments and allows for early ROM of the injured extremity. Plates provide strength and stability to neutralize the forces on the injured limb for functional postoperative aftercare (see the images below).

Preoperative radiographs showing a type B ankle fr Preoperative radiographs showing a type B ankle fracture.
Ankle fracture radiograph after open reduction and Ankle fracture radiograph after open reduction and internal fixation.

Plate designs vary, depending on the anatomic region and size of the bone the plate is used for. All plates should be applied with minimal stripping of the soft tissue.

Plates may be divided into five types on the basis of their main functions, as follows [7] :

  • Buttress (antiglide) plates
  • Compression plates
  • Neutralization plates
  • Tension-band plate
  • Bridge plates

Locking plates or fixed-angle devices are also helpful.

Buttress plates encourage compression and counteract the shear forces that commonly occur with fractures that involve the metaphysis and epiphysis. These plates are commonly used with interfragmentary screw fixation. The buttress plate is always fixed to the larger main fracture fragment but does not necessarily require fixation through the smaller fragment, because the plate buttresses the small fragment into the larger fragment. To achieve this function requires appropriate plate contouring for adequate fixation and support.

Compression plates counteract bending, shear, and torsional forces by providing compression across the fracture site via the eccentrically loaded holes in the plate. These plates are commonly used in the long bones, especially the fibula, radius, and ulna, and in nonunion or malunion surgery.

Neutralization plates are used in combination with interfragmentary lag-screw fixation. The interfragmentary compression screws provide compression at the fracture site. This plate function neutralizes bending, shear, and torsional forces on the lag-screw fixation, as well as increases the stability of the construct. Neutralization plates are commonly used for fractures involving the fibula, radius, ulna, and humerus.

Bridge plates are useful in the management of multifragmented diaphyseal and metaphyseal fractures. Achieving adequate reduction and stability without disrupting the soft-tissue attachments to the bone fragments may be difficult and requires skill in the use of indirect reduction techniques. Care should be taken to obtain correction of rotation, length, and alignment with bridge plating.

A tension-band plate technique converts tension forces into compressive forces, thereby providing absolute stability. An example of this technique is the use of a tension-band plate for fixation of a transverse olecranon fracture.

A locking plate acts like an internal fixator. [45] There is no need to anatomically contour the plate onto the bone; consequently, bone necrosis is reduced, and a minimally invasive technique is possible. Locking screws directly anchor and lock onto the plate, thereby providing angular and axial stability. These screws are incapable of toggling, sliding, or becoming dislodged, thus reducing the possibility of a secondary loss of reduction, as well as eliminating the possibility of intraoperative overtightening of the screws.

The locking plate is indicated for poor-quality bone (ie, osteoporotic fractures), for short and metaphyseal segment fractures, and for bridging comminuted areas. These plates are also appropriate for metaphyseal areas where subsidence may occur or prostheses are involved. [46] Locking plates can only hold a reduction that has already been obtained.

Intramedullary nails

The use of intramedullary nails over the past half century has been widely accepted. These nails operate like an internal splint that shares the load with the bone and can be flexible or rigid, locked or unlocked, and reamed or unreamed.

Locked intramedullary nails provide relative stability to maintain bone alignment and length and to limit rotation. Ideally, intramedullary nailing allows for compressive forces at the fracture site, which stimulates bone healing. Intramedullary nails are commonly used for femoral and tibial diaphyseal fractures (see the image below) and, occasionally, humeral diaphyseal fractures. The advantages of intramedullary nails include minimally invasive procedures, early postoperative ambulation, and early ROM.

Midshaft femur fracture managed with open reductio Midshaft femur fracture managed with open reduction and internal fixation performed with use of an intramedullary nail.

Imaging for evaluation of results

C-arm fluoroscopy is valuable and often necessary in the OR to provide for and to evaluate the results of internal fixation before the patient leaves the surgical suite. Alternatively, portable radiography can be used if multiple radiographic images are not anticipated to be necessary. All staff within the operating suite should be protected from radiation, either with aprons or with lead shields, while fluoroscopy is in use. [47]

External fixation

In 1907, Belgian physician Albin Lambotte developed the technique of external fixation for the management of fractures. [48] External fixation provides fracture stabilization at a distance from the fracture site—without interfering with the soft-tissue structures that are near the fracture. This technique not only provides stability for the extremity and maintains bone length, alignment, and rotation without requiring casting but also allows inspection of the soft-tissue structures that are vital for fracture healing, as well as subsequent wound care.

Indications for external fixation (temporarily or as definitive care) are as follows:

Open fractures that have significant soft-tissue disruption (eg, type II or III open fractures)

  • Soft-tissue injury (eg, burns)
  • Pelvic fractures (see the first image below)
  • Severely comminuted and unstable fractures
  • Fractures that are associated with bony deficits
  • Limb-lengthening procedures (see the second image below)
  • Fractures associated with infection or nonunion
Pelvic fracture managed with external fixation. Pelvic fracture managed with external fixation.
Ilizarov fixator. Ilizarov fixator.

Polytrauma: early total care vs damage-control orthopedics

Soft-tissue injuries and potential open wounds are inflammatory foci that behave much like an endocrine organ by releasing mediators and cytokines both locally and systemically, leading to a systemic inflammatory response. Further surgical insult (ie, femoral nailing for a femur fracture) can aggravate this mediator response, resulting in a further immunologic response, known as the "second hit" phenomenon. [49] This, in turn, may exacerbate the patient’s clinical status and can lead to further morbidity as well as mortality.

Early total care is important; several studies have documented the advantages of early fixation of long-bone fractures, especially femur fractures. [49, 50, 51] These advantages include early mobilization with improved pulmonary function, shorter time on a ventilator, reduced morbidity and mortality, and easier nursing care.

Early definitive surgical care should only be considered in stable patients who have been adequately resuscitated, whereas those who are unstable should undergo damage-control orthopedics (DCO). This concept refers to an early debridement of surgical wounds, with minimally invasive temporary fixation of long-bone fractures and dislocations. External fixator pins should be placed outside the zone of injury and should avoid sites of planned future incisions.

DCO should be considered in patients who are hemodynamically unstable or those with hypothermia, an abnormal base deficit, or blood-clotting abnormalities/pulmonary complications. No single test is available yet to determine which patients are at risk for a major systemic inflammatory response following trauma; however, concern should be high in patients with Injury Severity Scale (ISS) scores higher than 40, those with ISS scores higher than 20 who have thoracoabdominal injuries, and those who have moderate-to-severe head injuries, among others. [7, 42]

Moderate-quality evidence exists that DCO results in shorter operating times and less blood loss than early total care. [42] Although studies have not yet shown that DCO results in a decrease in mortality in a broad population of trauma patients, it may be that the benefit is primarily in a subset of severely injured patients. [42] Even if an initial damage-control approach is taken, definitive management should be performed within 7 days from injury, once the patient is stabilized, to minimize the risk of infectious complications.

Minimally invasive percutaneous plate osteosynthesis

Krettek et al were prominent in developing the concept of minimally invasive percutaneous plate osteosynthesis (MIPPO) with indirect reduction. [52] This technique involves the use of anatomically preshaped plates and instrumentation to safely and effectively insert the plate percutaneously or through limited incisions. Various plates, clamps, and other devices aid in the reduction of the affected bones.

Certain advantages of MIPPO may include faster bone healing, reduced infection rate, decreased need for bone grafting, less postoperative pain, faster rehabilitation, and more aesthetic results. Some disadvantages may include difficulty with indirect reduction, increased C-arm exposure, malunion, pseudoarthrosis through diastases, and delayed union with flexible fixation in simple fractures. [46]

Biologic aids for fracture healing

The use of biologic agents that aid in fracture healing will be commonly used in fracture management. Currently, autologous and cadaveric bone grafts are used in fracture management. Autologous cancellous bone grafts are used to fill defects and to provide stimulus for growth. Cadaveric cortical bone grafting is commonly used to provide diaphyseal structural support and to aid in filling large diaphyseal deficits.

A number of organic and synthetic materials have been used to promote fracture healing. These include hydroxyapatite, tricalcium phosphate, and calcium sulfate. Other biologic agents that have been recognized as stimulators of fracture healing include peptide-signaling molecules (eg, bone morphogenic protein, transforming growth factor beta, gene family fibroblast growth factor, and platelet-derived growth factor) and immunomodulatory cytokines (interleukins 1 and 6). Some of these biologic agents are gaining popularity. Bone morphogenic protein, for example, is now commonly used in spine surgery to aid in interbody fusion.


Postoperative Care

Postoperatively, appropriate wound care and suture or staple removal is performed as directed by the physician. Depending on the type of fracture sustained by the patient, he or she may be immobilized in a splint or cast. Postoperatively, patients are examined at follow-up visits, usually within 1-2 weeks after their surgical procedure, and periodically thereafter until the fracture has healed and functioning has returned. Weightbearing status is dependent on the stability of the fracture or osteosynthesis construct.



Complications of casts

Complications of casts include the development of pressure ulcers, thermal burns during plaster hardening, and thrombophlebitis. The AO group commented that prolonged cast immobilization, or cast disease, can be responsible for creating circulatory disturbances, inflammation, and bone disease that result in osteoporosis, chronic edema, soft-tissue atrophy, and joint stiffness. [7]

These problems may be avoided by providing functional aftercare. Children in prolonged cast immobilization need to be especially watched and educated on cast care; they have been known to stick items between their cast and skin in an attempt to scratch and alleviate pruritus. Broken skin can lead to festering infection, and “lost” items inside the cast can lead to pressure ulcers. [39]

Complications of traction

Complications of traction include the development of pressure ulcers, pulmonary/urinary infections, permanent footdrop contractures (if the foot is positioned in equinus), peroneal nerve palsy, pin tract infection, and thromboembolic events (eg, deep venous thrombosis [DVT], pulmonary embolism). These complications stem from a lack of patient mobility, muscle atrophy, weakness, and stiffness that result from a fracture.

Complications of external fixation

Complications of external fixation include pin tract infection, pin loosening or breakage, interference with joint motion, neurovascular damage when pins are placed, malalignment caused by poor placement of the fixator, delayed union, and malunion.

Complications of surgical intervention


Complications of surgical intervention include local infection in the form of cellulitis or, in more serious cases, osteomyelitis and systemic infection in the form of sepsis. Early recognition of a local infection may prevent the development of sepsis and, thus, decrease patient morbidity.

The most common pathogen is Staphylococcus aureus. Other pathogens include group A streptococci, coagulase-negative staphylococci, and enterococci.

Appropriate antibiotics should be administered if an infection is suspected. A 2-week course of first-generation cephalosporins, such as cephalexin, is generally sufficient for superficial surgical site infections.

Serial C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) measurements should be obtained and may be used to assess treatment response to antibiotics, though these will naturally be elevated in the immediate postoperative period.

If infection cannot be eradicated with antibiotics, I&D of the surgical wound may be necessary. If the facture has healed, any hardware at the site of infection should be removed.

Unhealed, infected fractures are a complex problem and each instance must be approached uniquely.

Thromboembolic events

Thromboembolic events may occur after orthopedic trauma with prolonged patient immobilization. Patients with significant fractures who are immobile for 10 days or longer have a 67% incidence of thrombosis. [23]

Prophylaxis is effective in decreasing the incidence of deep vein thrombosis (DVT) in the immobilized extremity, [53] but it has not been shown to be effective in decreasing the incidence of fatal pulmonary embolism. In addition, prophylactic anticoagulation carries with it its own set of serious and life-threatening complications, such as bleeding.

Not all orthopedic patients have the same risk of DVT. One study suggested that the risk of DVT in those with orthopedic trauma distal to the knee is not elevated, and the risk in upper-extremity trauma is intuitively minimal. [42] Before using DVT prophylaxis, the risks and benefits of such therapy must be thoroughly explained to the patient.

Low-molecular-weight-heparin (LMWH) injectables such as enoxaparin have been shown to have the best efficacy versus adverse effect profile. [42]

Complications of bone healing

Delayed union is defined as a fracture that has not healed after a reasonable time period (the time in which it was expected to heal) has passed.

Nonunion is defined as a fracture with no possible chance of healing, no matter how long the initial treatment is carried out. Risk factors for nonunion are summarized in Table 1 (see Overview, Pathophysiology). Management consists of treatment of the cause of the nonunion and can include eradication of infection, [54] stabilization of the fracture, removal of interfering soft tissues, bone grafting, [55] and medical/nutritional modifications of comorbidities.

Malunion is defined as healing of bone in an unacceptable position in any plane, which leads to a disability for the patient, cosmesis, or the potential for the development of posttraumatic arthritis. Treatment involves surgical correction of the anatomic abnormality.


Long-Term Monitoring

Consultation with rehabilitation specialists can be useful in helping inpatients to ambulate with the aid of crutches or a walker and, ultimately, to decrease postoperative morbidity and expedite patients' discharge planning. Rehabilitation services can be invaluable for many individuals in helping them regain their ROM and strength once the fracture has healed.

The need for physiotherapy depends on the nature of the injury and the patient's motivation, educational level, and abilities. Physiotherapists can help patients to recover from joint stiffness and to maintain and restore ROM. These therapists can provide appropriate guidance with respect to exercises and activities that aid in the patient's healing process.

The timetable for follow-up visits varies, depending on the nature of the injury. All patients must be monitored closely for potential complications (see Complications). At the time of discharge after the initial care of the fracture, the patient should be made aware of all the follow-up requirements specified by the treating physician.