Guidelines For Management Of Common Orthopaedic Fractures

and Soft Tissue Injuries in the E.D / M.I.U

Northern Care Alliance
NHS Group

These guidelines are for the most common injuries. All injuries should be assessed on individual merit. If in any doubt please consult your E.D. Senior or the Ortho on-call Team.
For patients issued with a black boot or a futuro splint, please provide the manufacturers information leaflet.

UPPER LIMB - PAEDIATRIC SPECIFIC SHOULDER COMPLEX and ELBOW - GENERIC UNLESS SPECIFIED IN PAEDIATRIC SECTION

Diagnosis ED Treatment Follow-up Please Document Diagnosis ED Treatment Follow-up Please Document

Selfcare pathway - STERNOCLAVICULAR JOINT DISLOCATION - ANTERIOR Polysling VFC

# CLAVICLE - Under 11yrs Polysling / BAS Discharge with leaflet
Easy 8 discharge
- POSTERIOR (RARE) Polysling Refer Ortho on call
# CLAVICLE - 11 - 16 yrs Polysling / BAS VFC CLAVICLE # Polysling VFC

ELBOW - NO VISIBLE # / OR SPRAIN ACJ INJURY Polysling VFC

Collar & Cuff VFC
- WITH POSTERIOR FAT PAD
SHOULDER DISLOCATION Reduce - Polysling VFC 1st time? / Recurrent?
SUPRACONDYLAR # HUMERUS - UNDISPLACED Above elbow backslab VFC +/- ISOLATED GREATER TUBEROSITY #
- DISPLACED Above elbow backslab for comfort Refer Ortho on call Pulses? / Pink? / Warm?
SHOULDER DISLOCATION & SUSPECTED NOH # Polysling Refer Ortho on call
SHAFT RADIUS AND / OR ULNA # - UNDISPLACED
OR MINIMAL ANGULATION Above elbow backslab VFC
SHOULDER DISLOCATION - IRREDUCIBLE Polysling Refer Ortho on call

SHAFT RADIUS AND / OR ULNA # - DISPLACED SOFT TISSUE INJURY SHOULDER - MILD Collar and Cuff Discharge with reassurance Rotator cuff intact ?
Above elbow backslab Refer Ortho on call
OR ANGULATED › 20°
- POSSIBLE ROTATOR CUFF INJURY Collar and Cuff VFC Rotator cuff intact ?
# DISTAL RADIUS - UNDISPLACED OR MINIMALLY DISPLACED Futuro splint VFC
ATRAUMATIC ACUTE SHOULDER PAIN Collar and Cuff / XR VFC Infection excluded

# DISTAL RADIUS - DISPLACED OR ANGULATED Backslab Refer Ortho on call

PROXIMAL HUMERUS / NECK / GREATER TUBEROSITY # Collar and Cuff VFC
Selfcare pathway -
DISTAL RADIUS - 'TORUS' / BUCKLE # Futuro splint Discharge with leaflet SHAFT HUMERUS # - CLOSED / RADIAL NERVE INTACT Humeral Brace/ U Slab VFC
Easy 8 discharge

Reassure and discharge

SHOULDER
- OPEN COMPLEX
OR RADIAL NERVE INJURYand ELBOW Collar
- GENERIC
and CuffUNLESS SPECIFIED
ReferABOVE
Ortho on (Part
call 2 of 2)
WRIST - NO VISIBLE # / OR SPRAIN Wool and crepe / Futuro splint
with VFC details
DISTAL HUMERUS # - UNDISPLACED
Diagnosis/ Collar Ed
andTreatment
Cuff VFC Follow-up Please Document
EXTRA-ARTICULAR / NO NERVE INJURY

DISTAL HUMERUS # - DISPLACED / INTRA-ARTICULAR /

NEURAL COMPROMISE BAS for comfort Refer Ortho on call

DISTAL BICEPS RUPTURE Polysling VFC

FOREARM / HAND / WRIST / DIGITS - GENERIC UNLESS SPECIFIED ABOVE
DISLOCATED ELBOW - NO # Reduce / BE Backslab / Re-xray VFC - Refer Ortho on call
Diagnosis ED Treatment Follow-up Please Document if unable to reduce

RADIAL / ULNA SHAFT # - UNDISPLACED Above elbow backslab VFC DISLOCATED ELBOW - WITH # Above elbow backslab Refer Ortho on call Record NV status
(eg.NIGHTSTICK)
OLECRANON # - UNDISPLACED Above elbow backslab VFC
RADIAL / ULNA SHAFT #
Above elbow backslab Refer Ortho on call - DISPLACED Above elbow backslab Refer Ortho on call
- DISPLACED / MONTEGGIA / GALEAZZI
# RADIAL HEAD / NECK - UNDISPLACED / MINIMALLY Selfcare pathway -
DISTAL RADIUS # Polysling Discharge with leaflet
Below elbow backslab VFC DISPLACED Easy 8 discharge
- UNDISPLACED / MINIMALLY DISPLACED

DISTAL RADIUS # # RADIAL HEAD / NECK - DISPLACED / COMMINUTED Polysling VFC

+ / - MUA in Emergency Dept / Backslab Refer Ortho on call
- SIGNIFICANTLY DISPLACED / OPEN / NEURO DEFICIT
DISLOCATED RADIAL HEAD +/- # PROXIMAL ULNA Above elbow backslab Refer Ortho on call
Below elbow backslab - no thumb
SCAPHOID # VFC - Scaphoid Pathway Record positive clinical tests
immobilisation

SCAPHOID - SUSPECTED # Futuro splint - no thumb immobilisation VFC - Scaphoid Pathway Record positive clinical tests

1st MC # BASE / SHAFT Futuro splint with thumb extension VFC

1st MC - INTRA-ARTICULAR # - UNDISPLACED Futuro splint with thumb extension VFC

PELVIS / HIP / FEMUR - GENERIC
1st MC - INTRA-ARTICULAR #
- DISPLACED (BENNETT'S) FOREARM / HAND / WRIST / DIGITS - GENERIC UNLESS Refer Ortho on call
SPECIFIED ABOVE (Part 2 or 2) Please
Diagnosis ED Treatment Follow-up Document
5th MC - # NECK (NO ROTATION) Buddy strap / wool and crepe Discharge with leaflet Selfcare pathway
Diagnosis
LESS THAN 40˚ ANGULATION Ed Treatment Follow-up se Document
- Easy 8 discharge
PELVIC #'s
2nd - 5th MC # SHAFT / BASE Buddy strap and Futuro splint VFC Clinical evidence of rotational
deformity -APC-Anterior Posterior ATLS / Treat hypovalaemia / +/- Pelvic Refer Ortho on call
Compression / LC-Lateral Binder
DISLOCATED 2nd - 5th CMC JOINT(S) Refer Ortho on call Refer Ortho on call if unable to reduce Compression / VS-Vertical Shear
CARPAL BONE - MINOR AVULSION Futuro splint VFC - LOW ENERGY ISOLATED Refer Medicine for social support.
Analgesia / Mobilise FWB walking
PUBIC RAMUS If failed mobility assessment - Refer
PROXIMAL / MIDDLE PHALANX # - UN / MINI- Selfcare pathway - Ensure NO aid as required
Buddy strap Discharge with leaflet Ortho on call
MALLY DISPLACED Easy 8 discharge rotational deformity
PROXIMAL / MIDDLE PHALANX Analgesia / Mobilise FWB walking
Reduce / Buddy strap VFC Refer Ortho on call if unable to reduce - AVULSION VFC
- DISPLACED / ROTATED aid as required

DISLOCATED MCP / IP JOINTS Reduce and Buddy strap VFC Refer Ortho on call if unable to reduce ACETABULAR # Analgesia Refer Ortho on call

DISLOCATED CMC JOINT Reduce and Buddy strap VFC Refer Ortho on call if unable to reduce Follow # NOF pathway / Fascia
NECK OF FEMUR # Refer Ortho on call (fast track bed)
iliaca nerve block
CRUSH TERMINAL PHALANX # - CLOSED Trephine if required VFC Follow # NOF pathway CT in E.D. to exclude fracture
SUSPECTED NOF # - NORMAL X-RAY
(NO nerve block ) Refer Ortho on call if fractured (fast track)
CRUSH TERMINAL PHALANX # - OPEN Wound washout +/- nail bed repair / Antibiotics VFC
Treat hypovalaemia / Fascia iliaca
MALLET FINGER - SOFT TISSUE / BONY ED direct referral to Selfcare pathway - SHAFT FEMUR # Refer Ortho on call
Mallet splint
Hand Therapy Easy 8 discharge
nerve block / Thomas splint
(LESS THAN 1/3 ARTICULAR SURFACE)

MALLET FINGER - BONY MORE THAN

Mallet splint VFC DISTAL FEMUR # +/- INTRA-ARTICULAR Analgesia Refer Ortho on call
1/3 ARTICULAR SURFACE

KNEE / PFJ - GENERIC SHAFT TIBIA / FIBULA /ANKLE / FOOT / TOES - GENERIC

Diagnosis ED Treatment Follow-up Please Document

Diagnosis ED Treatment Follow-up Please Document
Assessed for compartment
VFC - if apyrexial / normal CRP &ESR
TIBIAL SHAFT # - CLOSED / UNDISPLACED Above knee backslab Refer Ortho on call
syndrome
ATRAUMATIC SWOLLEN KNEE H/O Gout - discharge or Rheumatology.
(native knee not TKR) X-ray and bloods Exclude infection - DISPLACED /
Underlying OA - only refer Ortho on call Assessed for compartment
if failed mobility assessment. INTRA-ARTICULAR (PILON) Analgesia / reduce / above knee backslab Refer Ortho on call
syndrome
PATELLA - # UNDISPLACED Cricket pad splint / WB +/- walking aid VFC Record ability to straight leg
MIDSHAFT / NECK FIBULA # - ISOLATED STABLE Exclude associated ankle injury
raise (SLR) Wool and crepe - WB +/ - walking aid VFC
INJURY (Maisonneuve)
- # DISPLACED Cricket pad splint / WB +/- walking aid Refer Ortho on call Record ability to straight leg
raise (SLR)
WEBER A / WEBER B #'s (NO TALAR SHIFT) or Record presence of medial pain /
Black boot - WB +/ - walking aid VFC
? PATELLA / QUADS TENDON RUPTURE Cricket pad splint / WB +/- walking aid Refer Ortho on call Record ability to straight leg raise AVULSION # bruising
(SLR)
TIBIO- FEMORAL DISLOCATION Reduce / analgesia Refer Ortho on call / admit Record NV status pre and post WEBER B / WEBER C / BIMALLEOLAR /
reduction TRIMALLEOLAR - DISPLACED / Reduce if required / back slab / re-xray Refer Ortho on call
UNSTABLE #'s / MAISONNEUVE
PATELLO-FEMORAL DISLOCATION - FIRST TIME / Reduce / cricket pad splint / WB as Refer VFC
RECURRENT comfortable Record 'first time' or recurrent
Repeat XR - AP/lat/skyline . ISOLATED MEDIAL MALLEOLUS # - UNDISPLACED Black boot / toe touch WB VFC Record fibula tenderness / exclude
high fibula #
KNEE PAIN - POST LOW ENERGY TRAUMA - NO WB / Walking aid if required Refer Physio - DISPLACED Reduce if required / back slab / re-xray Refer Ortho on call
EFFUSION / GOOD ROM
Pt unable to WB - VFC
KNEE PAIN WITH - SIGNIFICANT MECHANISM OF WB as tolerated +/- walking aid / x-ray ANKLE SPRAIN RICE +/- Black boot if severe +/- walking aid Pt able WB - D/C with leaflet +/-
VFC
INJURY / EFFUSION / LIMITED EXAM DUE TO PAIN / if indicated Physio
HAEMARTHROSIS - ? MAJOR LIGAMENTOUS INJURY

INTERCONDYLAR TIBIAL AVULSION Above knee back slab full extension CALCANEUM # - UNDISPLACED / MINIMAL
VFC DVT prophylaxis Black boot NWB VFC DVT prophylaxis
# (STABLE KNEE) - repeat x-ray / NWB DISPLACEMENT
Refer Ortho on call / admit if
TIBIAL PLATEAU # - UNDISPLACED Above knee back slab / walking aid Refer Ortho on call Assessed for compartment - DISPLACED / COMMINUTED Back slab / elevate
indicated
syndrome
TALUS / CALCANEUM SMALL AVULSION
- DISPLACED Above knee back slab / walking aid Refer Ortho on call Assessed for compartment Black boot - FWB VFC
syndrome FRACTURES
SHAFT TIBIA / FIBULA /ANKLE / FOOT / TOES - GENERIC (Part 2 of 2)
TA ROM boot or back slab 30 deg equinous - Confirm if USS requested / DVT
TENDO ACHILLES RUPTURE - ABNORMAL
NWB. Refer for urgent OP USS if clinically VFC
SQUEEZE TEST Diagnosis Ed Treatment Follow-up Please Document
prophylaxis
diagnosis unclear (7/7 turnaround)
MIDFOOT INJURIES - AVULSION TARSAL # Black boot - FWB VFC
Document any bruising around
foot including sole.
- TARSAL # UNDISPLACED Black boot - NWB VFC
weight-bearing x-rays as tolerated
SPINAL INJURIES - TARSAL # DISPLACED Back slab Refer Ortho on call

Incidental osteoporotic wedge fractures seen on x-ray but not tender should not be referred. MULTIPLE METATARSAL #'s / CRUSHED FOOT Backslab / elevate - NWB Refer Ortho on call Assessed for compartment
/ ? LISFRANC syndrome
Trauma related osteoporotic wedge fractures should not all be referred for T&O review.
5th METATARSAL BASE # - EXCLUDING Selfcare pathway -
Need to identify cause of fall - if medical - refer to Medicine. Black boot - WB +/- walking aid Discharge with leaflet
METAPHASEAL (JONES) # 1.5 to 3cm Easy 8 discharge
Other patients should only be referred to Ortho on call if they fail mobility assessment. - distal to proximal tubercle

5th METATARSAL BASE # - METAPHASEAL Black boot - WB +/- walking aid VFC
Diagnosis ED Treatment Follow-up Please Document (JONES #) - distal to proximal tubercle

CERVICAL # - Trauma related Analgesia. Immobilise Refer Ortho on call Record NV status ISOLATED HALLUX METATARSAL / LESSER
Black boot / 'post-op' shoe - full or heel WB VFC
METATARSAL #'s
THORACIC # - Trauma related Analgesia. Immobilise Refer Ortho on call Record NV status TOE PHALANX # - UN / MINIMALLY DISPLACED Buddy strap / 'post-op' shoe - WB as Discharge with leaflet Selfcare pathway -
/ CLOSED comfortable Easy 8 discharge
LUMBAR # - Trauma related Analgesia. Immobilise Refer Ortho on call Record NV status - DISPLACED 'Post-op' shoe - full or heel WB VFC
HALLUX DISLOCATION 'Reduce / Elastoplast toe spica VFC
SEVERE LBP +/- RADICULAR PAIN GP to refer to local Spinal MSK Record NV status - WB +/- 'post-op' shoe
Analgesia
- NO CES / RED FLAGS service and Ix results
LESSER TOE DISLOCATIONS
DO NOT REFER to VFC - MTPJ - traumatic +/- deformity Reduce / buddy strap - WB VFC
SIMPLE 'STRAINS' / SPRAINS / Analgesia
- GP to refer to local MSK
WHIPLASH INJURIES - IPJ's - isolated / reducible / Reduce / buddy strap - WB Discharge with reassurance Selfcare pathway
Physiotherapy service no associated injuries

Ref: 78949
PLEASE AVOID USE OF BACKSLABS UNLESS ADVISED ABOVE. ALL OPEN FRACTURES TO BE REFERRED TO ORTHO ON CALL TEAM