Frimley GuidelinesFrimley Health Guidelines

Adult Fractures in ED (FPH)

Version:	1.1
Date Issued:	October 2023
Review Date:	January 2027
Key words:	Injury, fracture, adult

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Abbreviations

ACL	Anterior Cruciate Ligament
CMCJ	Carpometacarpal Joint
CT	Computed Tomography
DIPJ	Distal Interphalangeal Joint
MCL	Medial Collateral Ligament
MCPJ	Metacarpophalangeal Joint
PIPJ	Proximal Interphalangeal Joint
POP	Plaster of Paris
VFC	Virtual Fracture Clinic
XR	X-ray/Plain Radiograph

1. General Principles

Assess and document the neurovascular status distal to any fracture.
Prescribe appropriate analgesia both during assessment in the ED and on discharge.
Repeat x-ray and neurovascular status assessment post reduction of any fracture or dislocation.
Repeat x-ray in all wrist fractures post backslab POP application, even if no reduction required.

2. Open Fractures

For guidance on management of open fractures, see South West Trauma Network Open Fracture Pathway

3. Paediatric Injuries

For guidance on management of paediatric injuries, see Paediatric Skeletal Trauma guideline.

4. Upper Limb Injuries

4.1 Shoulder

INJURY	SUBCATEGORY	ED MANAGEMENT	NOTES
Clavicle fracture		Polysling, VFC referral
Shoulder / glenohumeral joint dislocation	Without fracture	Reduce, polysling, repeat XR, VFC referral
Sternoclavicular joint dislocation		Refer ortho on-call
Sternoclavicular joint subluxation		Polysling, VFC referral
Acromioclavicular joint dislocation		Polysling, VFC referral
Glenohumeral joint dislocation	With fracture	Polysling, VFC referral	Refer ortho on-call
Rotator cuff tear		Polysling, Physiotherapy referral, discharge to GP
Calcific tendonitis		Polysling, Physiotherapy referral, discharge to GP
Scapula fracture	With glenoid involvement	CT, refer ortho on-call	Exclude thoracic injury
	Without glenoid involvement	Polysling, VFC referral	Exclude thoracic injury
	Floating shoulder	CT, refer ortho on-call	Exclude thoracic injury

4.2 Humerus

INJURY	SUBCATEGORY	ED MANAGEMENT	NOTES
Proximal humerus fracture	Undisplaced / displaced	Collar & cuff, VFC referral
	Fracture with head split	Collar & cuff, CT, VFC referral	Ortho team to request CT if indicated
Isolated humeral greater tuberosity fracture		Polysling, VFC referral
Midshaft humerus fracture		Collar & cuff, VFC referral
Distal humerus fracture		Refer ortho on-call
Biceps tendon injury	Long head of biceps injury/rupture	Polysling, VFC referral
	Distal biceps injury/rupture	Polysling, urgent US, VFC referral

4.3 Elbow

INJURY	SUBCATEGORY	ED MANAGEMENT
Elbow dislocation	Without fracture	Reduce, polysling, repeat XR, VFC referral
	With undisplaced fracture	Reduce, polysling, repeat XR, VFC referral
	With displaced fracture	Reduce, CT, refer ortho on-call
Olecranon fracture	Undisplaced	Above elbow backslab POP, VFC referral
	Displaced	Above elbow backslab POP, refer ortho on-call
	Coronoid process	Above elbow backslab POP, CT, refer ortho on-call

4.4 Forearm

INJURY	SUBCATEGORY	ED MANAGEMENT	NOTES
Radial head fracture	Occult / undisplaced / minimally displaced	Polysling, VFC referral
	Displaced	Refer ortho on-call
	Multiple fractures	Above elbow backslab POP, CT. refer ortho on-call
Radial neck fracture	Occult / undisplaced / minimally displaced	Polysling, VFC referral
	Displaced	Refer ortho on-call
Radial shaft fracture		Above elbow backslab POP, XR wrist + elbow, refer ortho on-call	Exclude Galeazzi fracture
Proximal ulna fracture		Above elbow backslab POP, refer ortho on-call	Exclude Monteggia fracture
Ulna shaft fracture	Undisplaced	Above elbow backslab POP including wrist, VFC referral
	Displaced / comminuted / radial fracture	Above elbow backslab POP including wrist, refer ortho on-call
Radial + ulna fracture		Above elbow backslab POP, XR wrist + elbow, refer ortho on call

4.5 Wrist

INJURY	SUBCATEGORY	ED MANAGEMENT	NOTES
Undisplaced distal radius fracture		Below elbow backslab POP, repeat XR, VFC referral
Colles’ fracture		Reduce, below elbow backslab POP, repeat XR, VFC referral
Smith’s fracture		Reduce, volar slab POP, repeat XR, refer ortho on-call
Intra-articular distal radius fracture	Undisplaced	Below elbow backslab POP, repeat XR, VFC referral
	Displaced	Reduce, below elbow backslab POP, repeat XR, refer ortho on-call
Radial styloid fracture		Below elbow backslab POP, repeat XR, VFC referral	Assess scapholunate ligament

4.6 Hand

INJURY	SUBCATEGORY	ED MANAGEMENT	NOTES
Scaphoid fracture	Suspected	Futura splint, VFC referral
	Confirmed	Backslab POP, Closed Hand VFC
Carpal bone fracture (NOT Scaphoid)	Small / undisplaced	Futura splint, Closed Hand VFC	Exclude MCJ dislocation
	Displaced	Backslab POP, CT, Closed Hand VFC
Carpal/Perilunate/Lunate dislocation		Backslab POP, refer ortho on-call
Scapholunate ligament injury		Clenched fist view XR, Futura splint, Closed Hand VFC
Ligament injury (NOT Scapholunate)		Futura splint, Closed Hand VFC
1^st metacarpal fracture	Undisplaced	Thumb spica, Closed Hand VFC
	Displaced	Reduce, thumb spica, repeat XR, Closed Hand VFC
	Multifragmentary	Thumb spica, refer ortho on-call
2^nd – 5^th metacarpal fracture	Single neck/shaft <45° angulated / no shortening / no rotational deformity	Buddy strap, Closed Hand VFC
	Single neck/shaft >45° angulated / shortened / rotational deformity	Buddy strap, Closed Hand VFC
	Multiple metacarpal fractures	Reduce, Edinburgh position backslab POP, repeat XR, Closed Hand VFC
	Base / intra-articular, unicondylar / undisplaced	Futura splint, Closed Hand VFC	Exclude CMCJ dislocation
	Intra-articular, bicondylar / displaced	Futura splint, Closed Hand VFC
	Multifragmentary	Futura splint, refer ortho on-call
1^st CMCJ dislocation		Reduce, thumb spica, repeat XR, Closed Hand VFC
1^st MCPJ dislocation		Reduce, thumb spica, repeat XR, Closed Hand VFC
2^nd – 5^th metacarpal base dislocation		Reduce, Edinburgh position POP, repeat XR, Closed Hand VFC
2^nd – 5^th DIPJ / PIPJ dislocation	Without fracture	Reduce, finger splint, repeat XR, Closed Hand VFC
	With fracture	Reduce, finger splint, repeat XR, Closed Hand VFC
2^nd – 5^th phalangeal fracture	Nailbed injury	Refer plastics on-call
	Shaft – undisplaced	Buddy strap, Closed Hand VFC
	Shaft – displaced / long oblique	Reduce, finger splint, repeat XR, Closed Hand VFC
	Intra-articular	Reduce, finger splint, repeat XR, Closed Hand VFC
Mallet injuries (fracture or soft tissue)		Mallet splint, Closed Hand VFC
Volar plate injury		Finger splint, Closed Hand VFC
Central slip injury		Finger splint, Closed Hand VFC
Collateral ligament injury finger		Buddy strap, Closed Hand VFC
Ulna collateral ligament injury		Thumb spica, Closed Hand VFC
Radial collateral ligament injury	Soft tissue / bony undisplaced	Thumb spica, Closed Hand VFC
	Bony displaced	Thumb spica, Closed Hand VFC

5. Lower Limb Injuries

5.1 Knee

INJURY	SUBCATEGORY	ED MANAGEMENT	NOTES
Meniscal injury		Weight bear as tolerated, VFC referral	Exclude locked knee
ACL injury		Hinge brace, weight bear as tolerated, VFC referral	Exclude locked knee / dislocation
Locked knee		Refer VFC + inform ortho on-call (does not require review)
MCL injury		Hinge brace / cricket pad splint, weight bear as tolerated, VFC referral
Flake fracture(s)		Hinge brace / cricket pad splint, weight bear as tolerated, VFC referral	Likely Collateral or ACL injury
Knee dislocation		Reduce, above knee backslab POP, repeat XR, refer ortho on-call
Patella fracture	Displaced	Above knee backslab POP, VTE assessment, refer ortho on-call
	Undisplaced	Cricket pad splint, weight bear as tolerated, VFC referral
Patella dislocation		Reduce, cricket pad splint, repeat XR, VFC referral
Distal femur fracture		Splint, refer ortho on-call
Tibial spine fracture	Displaced	Refer ortho on-call
	Undisplaced	Above knee backslab POP, VTE assessment, weight bear as tolerated, VFC referral
Tibial plateau fracture		Refer ortho on-call
Proximal fibula fracture		Refer ortho on-call	Exclude Maisonneuve or tibial plateau fracture

5.2 Ankle

INJURY	SUBCATEGORY	ED MANAGEMENT	NOTES
Weber A fracture		Black boot, fully weight bearing, VFC referral
Weber B fracture	No talar shift on weightbearing views	Black boot, weight bear as tolerated, VFC referral
	No talar shift but unable to obtain or tolerate weightbearing views	Below knee backslab POP, VTE assessment, non-weight bearing, VFC referral
	Talar shift	Below knee backslab POP, refer ortho on-call
Weber C fracture		Below knee backslab POP, VTE assessment, refer ortho on-call
Bimalleolar fracture		Below knee backslab POP, VTE assessment, refer ortho on-call
Trimalleolar fracture		Below knee backslab POP, refer ortho on-call
Posterior malleolus fracture		Below knee backslab POP, CT, VTE assessment, refer ortho on-call
Medial malleolus fracture	Isolated / undisplaced	Below knee backslab POP, VTE assessment, non-weight bearing, VFC referral	Exclude proximal fibula fracture
	Displaced / with proximal fibula fracture	Below knee backslab POP, VTE assessment, refer ortho on-call

5.3 Foot

INJURY	SUBCATEGORY	ED MANAGEMENT	NOTES
Talus fracture	Body / neck	Below knee backslab POP, CT, VTE assessment, refer ortho on-call
	Head avulsion fracture	Black boot, fully weight bearing, VFC referral
	Lateral talar process	Below knee backslab POP, CT, non-weight bearing, VTE assessment, VFC referral
Calcaneus fracture		Below knee backslab POP, CT, non-weight bearing, VTE assessment, VFC referral	Exclude other axial loading injury
Achilles tendon injury		Equinus POP, non-weight bearing, urgent OP USS, prescribe 4/52 VTE prophylaxis, VFC referral
Tarsal bone fracture	Avulsion fracture	Black boot, weight bear as tolerated, VFC referral
	Undisplaced	Black boot, non-weight bearing, VFC referral, CT if midfoot instability suspected
	Displaced	Below knee backslab POP, CT, VTE assessment, refer ortho on-call
Lisfranc injury	Confirmed	Below knee backslab POP, non-weight bearing, CT, VTE assessment, refer ortho on-call
	Suspected (with no abnormality on XR)	Weightbearing XR -> if abnormality seen, below knee backslab POP, CT, VTE assessment, refer ortho on-call
Midfoot sprain		Weight bearing XR to rule out Lisfranc injury, VFC referral
1^st metatarsal fracture		Black boot, partial weight bearing, VFC referral
5^th metatarsal fracture		Black boot or rigid shoe, weight bear as tolerated, VFC referral
2^nd – 4^th metatarsal fracture	Single	Black boot or rigid shoe, weight bear as tolerated, VFC referral
	Multiple	Below knee backslab POP, non-weight bearing, VTE assessment, VFC referral
Hallux phalanx fracture	Displaced	Rigid shoe, weight bear as tolerated, VFC referral
	Undisplaced	Rigid shoe, weight bear as tolerated, no follow up required
	Intra-articular	Rigid shoe, weight bear as tolerated, VFC referral
Lesser phalanx fracture	Displaced	Buddy strap, weight bear as tolerated, VFC referral
	Undisplaced	Buddy strap 4/52, weight bear as tolerated, no follow up required
Toe dislocation		Reduce, repeat XR, weight bear as tolerated, VFC referral

Full version control record

Version:	1.1
Guidelines Lead(s):	Dr Lorraine Apps, Consultant in Emergency Medicine; Mr Zuhair Nawaz, Consultant in Orthopaedic Surgery
Contributor(s):	Dr Catherine Wade – ST5 Registrar in Emergency Medicine; Mr Luke Ashby – ST4 Registrar in Orthopaedic Surgery; Mr Stefano Capella – SHO in Orthopaedic Surgery; Susan Hillan – VFC Physiotherapist; Sophie Jenner – VFC Physiotherapist; Mr Lee Walsh, ENP clinical lead; Ms Rebecca Owens, Consultant in Orthopaedic Surgery
Lead Director / Chief of Service:	Dr Nick Payne – Chief of Service in Emergency Medicine
Library check completed:	N/A
Ratified at:	FPH Emergency Medicine Clinical Governance Committee, 17 November 2021
Date Issued:	23 October 2023
Review Date:	January 2027
Pharmaceutical dosing advice and formulary compliance checked by:	N/A
Key words:	Injury, fracture, adult

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version History

Version	Date	Guideline Lead(s)	Status	Comment
1.0	Jan 2022	Dr L Apps, Mr Z Nawaz	Final	Approved at FPH Emergency Medicine Clinical Governance Committee, 17 November 2021
1.1	Oct 2023	Ms R Owens, Mr Z Nawaz	Interim	Hand patients now referred to Closed Hand Clinics. Lower limb injuries requiring immobilising require a VTE assessment. Shoulder/Glenohumeral dislocation w/o fracture combined.

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