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RHCG Fracture Management Guidance

What's New

Revised 27/10/2021: change to management of forearm shaft fracture with no clinical deformity

Always consider Non-Accidental Injury

If any neurovascular compromise keep patient nil by mouth and discuss with orthopaedics

For open fractures ensure normal principles are followed: photograph if possible, cover and administer antibiotics.

Upper Limb

Diagnosis

 

Management

Follow up

Parental advice

Clavicle fracture

 

Broad arm sling/polysling

If skin compromise discuss with orthopaedics

 

Routine follow up not required

VFC significantly displaced adolescent fractures

Advice leaflet (pdf)

AC joint disruption

 

Broad arm sling

Physio referral for follow up

 

Shoulder soft tissue injury

 

Broad arm sling

Physio referral for follow up

Gentle mobilisation as able

Shoulder dislocation

 

Reduction in ED or MIU, polysling

Physio referral

Face to face fracture clinic 2 weeks

 

Humeral Fracture


 

 

Proximal

Collar and cuff

VFC Review

Analgesia, advise to sleep inclined at about 45 degrees

Start gentle mobilisation at 14 days

Shaft

Assess radial nerve; inform ortho if not intact. Humeral brace and collar and cuff or long back slab plus sling.

Face to Face fracture clinic 2 weeks

Analgesia, tight T-shirt may help. Keep sling on.

Elbows

 

 

 

 

 Elbow dislocation

 

Reduce and apply backslab and provide collar and cuff;

Xray and call for Ortho assistance if not reducible.

No ortho involvement in ED then VFC

Ortho involved in ED then as per their instructions 

 

Elbow Injury

 

Effusion, posterior fat pad; no definite fracture seen

Collar and cuff

No follow-up

 

Mobilisation advice as able.

Supracondylar Humeral Fracture

 

 

Gartland 1
Undisplaced

Collar and cuff

No follow-up

Analgesia, advise to mobilise at 3 weeks and avoid jumping/falling for 6 weeks

Gartland 2
Minimally displaced

Apply backslab at more than 90 degrees then check x-ray

VFC

 

Gartland 2
Significant displacement
(Anterior humeral line does not pass through the capitellium)

Apply backslab in current position and contact ortho

Likely for surgical intervention

FU As per ortho

 

Gartland 3+
Markedly displaced

Document neurovascular assessment.

Apply backslab in current position

Call Ortho

Likely for surgical intervention

FU As per ortho

 

Lateral condyle fracture

Undisplaced

Backslab

Face to Face fracture clinic 1 week

 

Displaced

Backslab for comfort

Call ortho.

Likely for surgical intervention

FU As per ortho

 

Medial Epicondyle Fracture

Displaced/undisplaced

Check Ulnar nerve

Intact: backslab
Not: contact ortho

Face to face fracture clinic 1 week

 

Radial Neck Fracture

Undisplaced, angulated <25 degrees, not involving joint surface

Collar and cuff

 

No Follow-up

Mobilise as pain allows, discard sling after 14 days

Angulation, displacement  or intra-articular

Discuss with Orthopaedics

   

Forearm/Wrist Fractures

Look for Galeazzi/Monteggia patterns

Monteggia/Galeazzi
Call ortho

Follow up as per operative instructions

 

Forearm shaft

ALWAYS CHECK RADIOCAPITELLAR LINE!

 

 

No Clinical Deformity

 

Long arm complete cast

Face to Face fracture clinic 1 week

 

Clinical deformity

 

Discuss with orthopaedics for decision:

Consider manipulation under Entonox or Ketamine if appropriate.
May require admission and operative management.

As per orthopaedics

 

 

Wrist
Distal radius/ulna

 

Buckle fracture

 

Wrist splint 3 weeks

 

No follow-up

Parents advised to remove splint in 3 weeks (and give leaflet)

Undisplaced

Wrist splint

 

No follow-up

Parents advised to remove splint in 3 weeks

Displaced

Discuss with orthopaedics for decision:

Consider manipulation under Entonox or Ketamine if appropriate.
May require admission and operative management.

As per ortho

 

Wrist: Physeal injury

 

Undisplaced 

Backslab or removable splint

VFC

 

Displaced

Discuss with orthopaedics for decision:

Consider manipulation under Entonox or Ketamine if appropriate.
May require admission and operative management.

As per ortho

 

Scaphoid (Suspected>10 years)

Clinical

Wrist splint

Face to Face fracture clinic 10 – 14 days

 

Lower Limb

Diagnosis

 

Management

Follow up

Parental advice

Hip

SCFE

Call Ortho

Likely for surgical intervention

FU As per ortho

 

Femur

Neck

Call Ortho

Likely for surgical intervention

FU As per ortho

 

Shaft

 

Femoral nerve block and Thomas splint.

Liaise with ortho

Likely for surgical intervention

FU As per ortho

 

Distal femur

Call Ortho

As per ortho

 

Knee

Intra-articular fracture

Call Ortho

Likely for surgical intervention

FU As per ortho

 

Small effusion, weight bearing, no fracture

Soft tissue advice

Refer to Physio

 

 

Effusion, non weight bearing +/- fracture

Knee splint

VFC

May need face-to-face review and further imaging

Patella dislocation

Reduce

Refer to Physio

Face to Face fracture clinic 1 week

 

 

Patella Fracture

Undisplaced – splint

Displaced – call ortho

Sleeve – call ortho

Physio referral, VFC

As per ortho

As per ortho

 

 

Tibial tuberosity

Undisplaced – splint

Displaced – Call ortho

VFC

As per ortho

 

 

Tibial Eminence

Call Ortho

As per ortho

 

Tibia

 

 

 

 

 

 

 

Undisplaced shaft

Long leg full cast with ortho assistance as required

Face to Face fracture clinic 1 week

Physio referral

Elevate; To return if pain increases

Displaced shaft +/- fibula fracture

 

Call Ortho

As per ortho

 

Toddler fracture

Walking boot or if none small enough apply full cast

Face to face fracture clinic 3 weeks

 

Isolated fibular shaft fracture

Check ankle joint

Symptomatic treatment and walking boot.

Physio referral

VFC

 

Ankle

 

Ankle sprain

 

Symptomatic treatment

Physio referral

General soft tissue injury advice re rest, ice, elevation and maintain good ROM

Undisplaced Distal fibula fracture (isolated)

Walking boot

Physio referral

Remove boot 4 weeks

Advise to discard boot at 4 weeks and refrain from sport for 6 weeks

 

Displaced distal fibula fracture

Walking boot 

Physio Referral

Face to face fracture clinic 1 week

Any displaced distal tibia growth plate injury

Call ortho

As per post-reduction advice

 

Foot
Metatarsals

 

 

 

5th metatarsal Jones fracture in adolescent

Walking boot 4 weeks

Phsyio referral

Opt in fracture clinic

Weight bear as able

Isolated, undisplaced metatarsal shaft fracture

Walking boot

No follow-up

 

Multiple displaced metatarsal shaft fractures

Call ortho

As per ortho

 

Midfoot

Lisfranc injury (unstable; swelling+)

Call ortho

As per ortho

 

Calcaneum

Undisplaced

If undisplaced, walking boot

Assess for other injuries.

Physio referral

 

Displaced

Call ortho

As per ortho

 

Great toe

 

No deformity

Symptomatic treatment

Nil

Mobilise, symptoms for up to 6/52

Clinical deformity

Manipulate with ring block/entonox, elastoplast toe spica +/- moonboot

Nil

Remove boot at 3 weeks and mobilise as able

Other toes

Clinical deformity

X-ray, reduce as needed and buddy strap

No follow up needed

Mobilise, symptoms for up to 6/52

No deformity

No x-ray needed, buddy strap for comfort

No follow up needed

Mobilise, symptoms for up to 6/52

Specific patient injury pathways

Limps: These should be given an opt-in letter as usual. If they contact the ED secretary asking for a review they will also be added on to the next VFC and will be contacted by the orthopaedic team

Editorial Information

Last reviewed: 22 July 2022

Next review: 22 July 2025

Author(s): Ms Kim Ferguson (Consultant Orthopaedic Surgeon, RHCG) on behalf of RHCG Orthopaedic Service

Version: 2

Co-Author(s): Dr Steven Foster (Consultant in paediatric emergency medicine, RHCG) on behalf of RHCG Paediatric Emergency Department.