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Diagnosis |
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Management |
Follow up |
Parental advice |
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Clavicle fracture |
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Broad arm sling/polysling If skin compromise discuss with orthopaedics
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Routine follow up not required VFC significantly displaced adolescent fractures |
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AC joint disruption |
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Broad arm sling |
Physio referral for follow up |
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Shoulder soft tissue injury |
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Broad arm sling |
Physio referral for follow up |
Gentle mobilisation as able |
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Shoulder dislocation |
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Reduction in ED or MIU, polysling |
Physio referral Face to face fracture clinic 2 weeks |
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Humeral Fracture
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Proximal |
Collar and cuff |
VFC Review |
Analgesia, advise to sleep inclined at about 45 degrees Start gentle mobilisation at 14 days |
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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. |
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Elbows |
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Elbow dislocation |
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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 |
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Elbow Injury
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Effusion, posterior fat pad; no definite fracture seen |
Collar and cuff |
No follow-up
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Mobilisation advice as able. |
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Supracondylar Humeral Fracture
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Gartland 1 |
Collar and cuff |
No follow-up |
Analgesia, advise to mobilise at 3 weeks and avoid jumping/falling for 6 weeks |
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Gartland 2 |
Apply backslab at more than 90 degrees then check x-ray |
VFC |
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Gartland 2 |
Apply backslab in current position and contact ortho |
Likely for surgical intervention FU As per ortho |
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Gartland 3+ |
Document neurovascular assessment. Apply backslab in current position Call Ortho |
Likely for surgical intervention FU As per ortho |
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Lateral condyle fracture |
Undisplaced |
Backslab |
Face to Face fracture clinic 1 week |
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Displaced |
Backslab for comfort Call ortho. |
Likely for surgical intervention FU As per ortho |
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Medial Epicondyle Fracture |
Displaced/undisplaced |
Check Ulnar nerve Intact: backslab |
Face to face fracture clinic 1 week |
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Radial Neck Fracture |
Undisplaced, angulated <25 degrees, not involving joint surface |
Collar and cuff
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No Follow-up |
Mobilise as pain allows, discard sling after 14 days |
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Angulation, displacement or intra-articular |
Discuss with Orthopaedics |
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Forearm/Wrist Fractures |
Look for Galeazzi/Monteggia patterns |
Monteggia/Galeazzi |
Follow up as per operative instructions |
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Forearm shaft ALWAYS CHECK RADIOCAPITELLAR LINE!
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No Clinical Deformity
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Long arm complete cast |
Face to Face fracture clinic 1 week |
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Clinical deformity
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Discuss with orthopaedics for decision: Consider manipulation under Entonox or Ketamine if appropriate. |
As per orthopaedics |
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Wrist
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Buckle fracture
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Wrist splint 3 weeks
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No follow-up |
Parents advised to remove splint in 3 weeks (and give leaflet) |
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Undisplaced |
Wrist splint
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No follow-up |
Parents advised to remove splint in 3 weeks |
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Displaced |
Discuss with orthopaedics for decision: Consider manipulation under Entonox or Ketamine if appropriate. |
As per ortho |
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Wrist: Physeal injury
|
Undisplaced |
Backslab or removable splint |
VFC |
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Displaced |
Discuss with orthopaedics for decision: Consider manipulation under Entonox or Ketamine if appropriate. |
As per ortho |
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Scaphoid (Suspected>10 years) |
Clinical |
Wrist splint |
Face to Face fracture clinic 10 – 14 days |
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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.
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Diagnosis |
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Management |
Follow up |
Parental advice |
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Hip |
SCFE |
Call Ortho |
Likely for surgical intervention FU As per ortho |
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Femur |
Neck |
Call Ortho |
Likely for surgical intervention FU As per ortho |
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Shaft
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Femoral nerve block and Thomas splint. Liaise with ortho |
Likely for surgical intervention FU As per ortho |
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Distal femur |
Call Ortho |
As per ortho |
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Knee |
Intra-articular fracture |
Call Ortho |
Likely for surgical intervention FU As per ortho |
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Small effusion, weight bearing, no fracture |
Soft tissue advice |
Refer to Physio
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Effusion, non weight bearing +/- fracture |
Knee splint |
Refer to Physio Face to Face fracture clinic 1 week |
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Patella dislocation |
Reduce |
Physio referral |
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Patella Fracture |
Undisplaced – splint Displaced – call ortho Sleeve – call ortho |
Physio referral, VFC As per ortho As per ortho |
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Tibial tuberosity |
Undisplaced – splint Displaced – Call ortho |
VFC As per ortho |
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Tibial Eminence |
Call Ortho |
As per ortho |
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Tibia
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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 |
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Displaced shaft +/- fibula fracture
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Call Ortho |
As per ortho |
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Toddler fracture |
Walking boot or if none small enough apply full cast |
Face to face fracture clinic 3 weeks |
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Isolated fibular shaft fracture |
Check ankle joint |
Symptomatic treatment and walking boot. |
Physio referral VFC |
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Ankle
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Ankle sprain
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Symptomatic treatment |
Physio referral |
General soft tissue injury advice re rest, ice, elevation and maintain good ROM |
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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
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Displaced distal fibula fracture |
Walking boot |
Physio Referral Face to face fracture clinic 1 week |
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Any displaced distal tibia growth plate injury |
Call ortho |
As per post-reduction advice |
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Foot
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5th metatarsal Jones fracture in adolescent |
Walking boot 4 weeks |
Phsyio referral Opt in fracture clinic |
Weight bear as able |
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Base of 5thmetatarsal avulsion fractur |
Walking boot |
Nil |
Weight bear as able in walking boot for 2 weeks and then trainer for 2 weeks |
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Isolated, undisplaced metatarsal shaft fracture |
Walking boot |
No follow-up |
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Multiple displaced metatarsal shaft fractures |
Call ortho |
As per ortho |
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Midfoot |
Lisfranc injury (unstable; swelling+) |
Call ortho |
As per ortho |
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Calcaneum |
Undisplaced |
If undisplaced, walking boot Assess for other injuries. |
Physio referral |
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Displaced |
Call ortho |
As per ortho |
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Great toe
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No deformity |
Symptomatic treatment |
Nil |
Mobilise, symptoms for up to 6/52 |
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Clinical deformity |
Manipulate with ring block/entonox, elastoplast toe spica +/- moonboot |
Nil |
Remove boot at 3 weeks and mobilise as able |
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Other toes |
Clinical deformity |
X-ray, reduce as needed and buddy strap |
No follow up needed |
Mobilise, symptoms for up to 6/52 |
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No deformity |
No x-ray needed, buddy strap for comfort |
No follow up needed |
Mobilise, symptoms for up to 6/52 |
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