RHCG Fracture Management Guidance (940)

What's new / Latest updates

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
Humeral Fracture	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
Lateral condyle fracture	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
Radial Neck Fracture	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
Forearm shaft ALWAYS CHECK RADIOCAPITELLAR LINE!	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
Wrist: Physeal injury	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	Refer to Physio Face to Face fracture clinic 1 week
	Patella dislocation	Reduce	Physio referral
	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	5^th metatarsal Jones fracture in adolescent	Walking boot 4 weeks	Phsyio referral Opt in fracture clinic	Weight bear as able
	Base of 5^thmetatarsal avulsion fractur	Walking boot	Nil	Weight bear as able in walking boot for 2 weeks and then trainer for 2 weeks
	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
Calcaneum	Displaced	Call ortho	As per ortho
Great toe	No deformity	Symptomatic treatment	Nil	Mobilise, symptoms for up to 6/52
Great toe	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
Other toes	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

Last reviewed: 22/07/2022

Next review date: 22/07/2025

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

Version: 2

Document Id: 940

Related guidelines

RHCG Fracture Management Guidance (940)

Upper Limb

Lower Limb

Specific patient injury pathways

Editorial Information