How should I determine whether a patient with a fracture requires referral for specialist assessment or intervention?

To determine whether a patient with a fracture requires referral for specialist assessment or intervention, assess the following key factors:

• Fracture complexity and displacement: Complex fractures, intra-articular fractures, or those with displacement that cannot be reduced by closed manipulation generally require specialist referral for possible surgical intervention ¹,².
• Neurovascular status: Any evidence of neurovascular compromise (e.g., loss of sensation, weakness, absent or asymmetric pulses, compartment syndrome) mandates urgent specialist assessment ¹,⁵.
• Open wounds or skin tenting: Fractures complicated by open wounds or skin tenting require urgent referral for surgical management ¹.
• Age and skeletal maturity: Children with displaced fractures, especially involving growth plates or femoral shaft fractures, often require specialist input and admission ¹.
• Suspected non-accidental injury: Particularly in children with femoral fractures, safeguarding concerns should be addressed before discharge and may necessitate specialist involvement ¹.
• Failure of conservative management or uncertainty about stability: If there is uncertainty about fracture stability or symptoms are not improving, arrange orthopaedic follow-up or specialist referral within 2 weeks ¹.
• Specific clinical prediction rules: Use validated tools such as the Ottawa ankle and knee rules to guide imaging and referral decisions ¹,⁵.
• Associated complications: Fracture dislocations, vascular injury, or split of the humeral head in proximal humerus fractures require specialist consideration ¹.

In summary, refer patients urgently if there is neurovascular compromise, open fractures, irreducible displacement, or suspected non-accidental injury. Consider referral for specialist assessment if fracture stability is uncertain, symptoms worsen, or complex fracture patterns are present ¹,²,⁵.