| D/C home with info. leaflet for the relevant injury - Green |
| Refer to Virtual Fracture Assessment Clinic (vFAC) - Amber |
| Refer to ortho on call team - Red |
| Refer to another Service - Grey |
| Refer directly to fracture clinic - Purple (#s manipulated in ED/LIU, stable spine #s, consults seen by Ortho team) |
Injury/fracture |
Subcategory |
Initial treatment |
Follow-up |
Beware/pls document |
# Clavicle |
Children - undisplaced/greenstick | Triangular bandage/small poly sling | Discharge / advice leaflet | |
# Clavicle |
Adolescent(>14yo)/Adult | Poly sling | vFAC | If skin threatened refer to Ortho on call |
AC Joint injury |
Grade I-II | Poly sling | Discharge / advice leaflet | |
AC Joint injury |
Grade III-VI | Poly sling | vFAC | |
SC joint injury |
Anterior dislocation | Poly sling | vFAC | |
SC joint injury |
Posterior dislocation | Poly sling | Refer to Ortho on call | |
Dislocated Shoulder |
Reduce, Polysling | vFAC | If posterior, discuss with Ortho re reduction. Document if 1st First time or recurrent | |
Dislocated Shoulder |
Irreducible or assoc. fracture | Poly sling | Refer to Ortho on call | If posterior get advice from ortho for reduction |
ST shoulder inj |
? rotator cuff injury/ impingement/ tendonitis | Poly sling | ED/LIU Physio | GP to refer to elective upper limb clinic if still symptomatic |
ST shoulder inj |
Biceps tendon injury | Poly sling | vFAC | Document hook test positive for distal rupture |
Acute Atraumatic shoulder pain |
Incl. calcific tendonitis | Collar & cuff, exclude infection | GP to refer to elective clinic | Document no infection |
# Humerus |
Neck - undisplaced/impacted | Collar & cuff | vFAC | |
# Humerus |
Neck /greater tuberosity - significantly displaced | Collar & Cuff | Refer to Ortho on call | |
# Humerus |
Shaft | Humeral brace | vFAC | NV status, encourage early elbow & wrist ROM exercises to avoid stiffness |
# Humerus |
Supracondylar child undisplaced (Gartland type I) | High above elbow back slab | vFAC | X-ray in cast |
# Humerus |
Supracondylar child displaced | Above elbow back slab/position of comfort | Refer to Ortho on call | NV status |
# Humerus |
Distal/intra-articular | High above elbow back slab | Refer to Ortho on call | |
Elbow ST Inj (adult) |
No # seen. No fat pad. | C&C | ED/LIU Physio | |
Elbow tendonitis |
No # seen | C&C | ED/LIU Physio | |
Dislocated Elbow |
Reduce, Above elbow backslab | Fracture clinic | ||
Dislocated Elbow |
Irreducible/fracture | Poly sling | Refer to Ortho on call | NV status |
# Radial head/neck |
Undisplaced | Poly sling | Discharge / advice leaflet | |
# Radial head/neck |
Displaced | Poly sling | vFAC | X-ray wrist if DRUJ tender |
# Olecranon |
Undisplaced | Poly sling | vFAC | Document extension against gravity |
# Olecranon |
Displaced | Above elbow backslab | Refer to Ortho on call | |
# Forearm |
Undisplaced | Above elbow back slab | Fracture clinic | X-ray elbow and wrist |
# Forearm |
Displaced/ Monteggia/ Galeazzi dislocations | Above elbow back slab | Refer to Ortho on call | Document NV status |
# Distal radius |
Children's Torus/Buckle | Paediatric Wrist Splint / soft cast if splint too big | Discharge / advice leaflet | |
# Distal radius |
Children's minimally displaced/greenstick | Paediatric Wrist Splint | vFAC | |
# Distal radius |
Children displaced/angulated #s | Below Elbow back slab/position of comfort | Refer to Ortho on call | |
# Distal radius |
Adult minimally/ undisplaced | Wrist splint | vFAC | |
# Distal radius |
Displaced (high energy/open/neuro deficit/volar displacement) | |||
# Distal radius |
With above features | Backslab | Refer to Ortho on call | NV status |
# Distal radius |
Without above features | ED MUA, Backslab, check reduction with ortho on call | Fracture clinic | X-ray in cast and document ortho on call happy with reduction |
# Distal radius |
Smith's # (extra articular volar angulated without above features) | EM MUA, Volar Backslab with wrist extended | Fracture clinic | X-ray in cast & document ortho on call happy with reduction |
# Distal radius |
Low functional demand (e.g. dementia/paralysed limb) | Below elbow backslab | Fracture clinic | X-ray in cast, document that Ortho on call happy with reduction |
? # Scaphoid |
? Possible # vs wrist sprain | Wrist splint | ED/LIU Physio | Re-x-ray @ 10/7, if still symptomatic. If # refer to vFAC Amber pathway |
# Scaphoid |
Obvious # | Scaphoid backslab | Fracture clinic | Beware perilunate dislocation, NV status |
Other Carpal # /injury |
Undisplaced e.g. triqetral # | Wrist splint | vFAC | |
Wrist/hand/finger ST Inj. |
No # | Wrist splint/buddy strap | ED/LIU Physio | |
Wrist/thumb tendonitis |
No # | Wrist thumb splint | ED/LIU Physio | |
Thumb MC lig. injury |
No obvious #, ? UCL/RCL | Thumb splint | vFAC | Consider stress x-ray to confirm diagnosis |
# Thumb metacarpal |
Undisplaced base/shaft | Thumb splint | vFAC | |
# Thumb metacarpal |
Displaced /intra-articular (Bennett’s) | EM MUA & cast | vFAC | X-ray in cast & document ortho happy with reduction |
# 1st Metacarpal |
Irreducible / unstable pattern | Thumb splint | Refer to Ortho on call | |
# 5th Metacarpal |
Neck | Buddy strap | Discharge / advice leaflet | |
# Metacarpal |
Base / shaft : undisplaced | Futura splint | vFAC | Lat. x-ray to ensure CMCJ not displaced |
# Metacarpal |
Base / shaft : displaced / rotational deformity | EM MUA , Volar slab Edinburgh position | Fracture clinic | X-ray in cast, document ortho happy with reduction |
# Metacarpal |
Base / shaft : irreducible | Volar slab | Refer to Ortho on call | |
# Metacarpal |
Open fracture | Clean, IVAB | Refer to plastics on call | |
Dislocated MCP/IP joints |
Reducible | EM MUA, buddy strap, mobilise early | vFAC | Need early hand therapy |
Dislocated MCP/IP joints |
Irreducible / unstable pattern | Buddy strap | Refer to Ortho on call | |
# Phalanx |
Open fracture | Analgesia, clean, ATT etc | Refer to Plastics on call | |
# Phalanx |
Proximal / Middle : undisplaced | Buddy strap | vFAC | |
# Phalanx |
Proximal / Middle : displaced / rotational deformity | EM MUA, Buddy splint | vFAC | Check x-ray |
# Phalanx |
Proximal / Middle: irreducible | Buddy strap | Refer to Ortho on call | |
# Phalanx |
Volar plate PIPJ | Buddy strap | vFAC | |
# Phalanx |
# Distal phalanx-tuft #- crush injury closed | Trephine nail / clean, dress | Refer plastics on call | |
# Phalanx |
Distal - crush injury open | Clean / dress / antibiotics | Refer to plastics on call | |
Mallet finger |
Bony >25% joint surface, joint subluxed | Mallet splint | Refer to Ortho on call | |
Mallet finger |
Non bony/<25% joint surface, joint subluxed | Mallet splint, need early hand therapy | vFAC | |
Mallet finger |
Non bony/<25% joint surface, joint not subluxed | Mallet splint | Refer to plastics on call | Need early hand therapy |
Central Slip rupture/Acute Boutonnière |
No fracture | Refer to Plastics on call | Note passive extension of PIPJ but no active extension | |
Nail bed injury - simple |
No fracture | EM team to review | Refer to plastic team if concerns | |
Nail bed injury - complex |
No fracture | Refer to Plastics on call | ||
Penetrating palm/finger wound |
No fracture | Irrigate wound, dress, antibiotics, tetanus | Refer to Plastics on call | NV status |
Possible tendon/nerve injury |
No fracture | Refer to Plastics on call | ||
Concerning hand infection |
No fracture | Refer to Plastics on call | ||
Any open fracture distal to wrist |
Open fracture | Refer to Plastics on call | ||
Upper limb Compartment Synd. |
Upper limb compartment Syndrome | Refer to Plastics on call | ||
Upper Limb Compartment Synd. with # |
Compartment Syndrome | Refer to Ortho on call | ||
| Injury/fracture | Category | Initial treatment | Follow-up | Note | |
|---|---|---|---|---|---|
Pelvis fracture |
APC, LC, VS | Treat hypovolaemia + CT | Refer to Ortho on call | ||
Pelvis fracture |
# Pubis rami | Analgesia, Mobilise as able (crutches/Frame) | Refer to Geriatrics/Medics if can't mobilise | CT - if evidence of sacral / SIJ injury | |
Pelvis fracture |
Avulsion # | Analgesia, Mobilise as able (crutches/Frame) | vFAC | ||
Acetabular # |
Analgesia, CT | Refer to Ortho on call | |||
# Neck of Femur |
Hip pathway | Refer to Ortho on call | Hip pain but no obvious # - CT | ||
Dislocated THR |
1st dislocation | Refer to Ortho on call | May need reduction in theatre if <6/52 post op | ||
Dislocated THR |
Recurrent | EM to reduce, Analgesia, Crutches/frame WBAT | vFAC | ||
Hip STI |
No #/tendonitis/bursitis | Mobilise as able, consider crutches | ED/LIU Physio | ||
Groin/Quads/Hamstring strain |
No # | Mobilise as able, consider crutches | ED/LIU Physio | ||
# Femoral Shaft |
Nerve block, skin traction, IV fluids, bloods, Xmatch | Refer to Ortho on call | |||
# Distal Femur |
Analgesia, above knee backslab | Refer to Ortho on call | |||
Thigh injury/haematoma |
Exclude compartment syndrome | Discharge / advice leaflet | Consider asking ED physio to see prior to D/C | ||
Thigh injury/haematoma |
Needing evacuation / ? compartment synd. | Refer to ortho team on call | If skin loss, consult plastics on call | ||
Open wound over knee joint |
Deep wound, requiring washout, without skin loss | IV Antibiotics, tetanus, knee splint | Refer to Ortho on call | If skin loss, consult plastics on call | |
# Patella |
Undisplaced | Knee splint, crutches, WBAT | vFAC | NB - bipartite patella = normal variant | |
# Patella |
Displaced | Knee splint/above knee backslab | Refer to Ortho on call | ||
Soft tissue knee injury, no # |
? Meniscal/ligament injury, | Tubigrip/knee splint/advice leaflet | ED/LIU Physio | Outrule knee dislocation / NV status, consider asking ED physio to see prior to D/C | |
Locked knee |
Unable to fully extend, physical block to flexion | Refer Ortho on call | |||
Patella dislocation |
No assoc. # | Reduce, AP/Lat. skyline x-rays | vFAC | Document 1st or recurrent | |
Patella dislocation |
With assoc. # | Reduce, AP/Lat. skyline x-rays | Refer Ortho on call | ||
Atraumatic swollen knee |
Pyrexial, ↑ ESR/CRP /WBC | ? Septic arthritis | Refer Ortho on call | If not septic arthritis refer to medics/rheumatology for gout work up | |
Patella/Quads rupture |
Knee splint | Refer to Ortho on call | |||
# Tibial spine |
Undisplaced | Above knee backslab, WBAT crutches, x-ray in backslab | Fracture clinic | Document ortho on call happy with check x-ray position | |
# Tibial spine |
Displaced | Above knee backslab, CT | Refer to Ortho on call | ||
Osgood-Schlatter's |
Mobilise as able, consider crutches | ED/LIU Physio | |||
# Tibial plateau |
Undisplaced | Knee splint, crutches, NWB, CT to confirm undisplaced | vFAC | ||
# Tibial plateau |
Displaced | Knee splint, CT | Refer to Ortho on call | Document NV status | |
# Tibial shaft |
Undisplaced | Above knee backslab | Refer to Ortho on call | X-ray after cast | |
# Tibial shaft |
displaced | Above knee backslab | Refer to Ortho on call | Ensure not open, document NV status | |
Open tibial shaft # |
Open fracture | IV antibiotics, tetanus, splint | Refer to Ortho on call | If skin loss, consult plastics on call for combined care | |
Traumatic compartment Syndrome |
Traumatic compartment synd. ±# | Splint | Refer to Ortho on call | ||
# Tibial pilon (intra-articular distal tibia) |
BK backslab, CT | Refer to Ortho on call | Ensure not open, document NV status | ||
# Fibular proximal/shaft |
Undisplaced with no ankle involvement | Airboot/ knee brace, (pending location) WBAT, crutches | vFAC | Ensure not Maisonneuve #, X-ray ankle | |
Calf strain |
Rule out Achilles #/DVT | Tubigrip, WBAT, crutches, consider Airboot | ED/LIU Physio | ||
# Ankle |
Weber A | Airboot, WBAT, crutches | vFAC | ||
# Ankle |
Undisplaced Weber B - no talar shift, no medial tenderness | Airboot, WBAT, crutches | vFAC | ||
# Ankle |
Isolated medial malleolus - undisplaced | Airboot, WBAT, crutches | vFAC | Ensure not Maisonneuve # | |
# Ankle |
Displaced/unstable Weber B/bi-tri-malleolar/Weber C | EM MUA, BK backslab | Refer to Ortho on call | ||
# Ankle |
Isolate medial malleolus - displaced | BK backslab | Refer to Ortho on call | Ensure not Maisonneuve # | |
Child’s ankle SH 1/2 #s |
Undisplaced | Airboot, WBAT, crutches | vFAC | ||
Child’s ankle triplane / Tillaux # |
BK backslab | Refer to Ortho on call | X-ray in cast | ||
Adult Ankle sprain |
No # | Tubigrip, WBAT, crutches, consider Airboot | ED/LIU Physio | ||
Ankle avulsion # |
Small avulsion #, tip lat. mall/talus/calcaneus incl. Slater Harris type 1/2 distal fibular #s | Airboot, tubigrip, WBAT, crutches | vFAC | ||
Tendoachilles rupture |
Positive squeeze test | Backslab in equinus, crutches, NWB | Refer to Ortho on call | Low threshold for DVT prophylaxis | |
Achilles/Tib. post tendonitis |
Rule out complete rupture | Tubigrip, WBAT, crutches, consider Airboot | ED/LIU Physio | Document not complete rupture | |
Open wound over Achilles tendon |
Wound requiring washout, without skin loss | IV antibiotics, tetanus | Refer to Ortho on call | If skin loss, consult plastics on call | |
Open wound over ankle joint |
Wound requiring washout, without skin loss | IV antibiotics, tetanus, splint | Refer to Ortho on call | If skin loss, consult plastics on call | |
# Calcaneus |
Undisplaced | Airboot, BK backslab, NWB | vFAC | Ensure elevation advice | |
# Calcaneus |
Displaced / extra-articular tongue type | CT | Refer to Ortho on call | Tented skin over heel can rapidly break down, may need equinus cast | |
Sever's disease |
Mobilise as able, consider Airboot | ED/LIU Physio | |||
Plantar fasciitis |
Mobilise as able, consider Airboot | ED/LIU Physio | |||
# Talus |
Undisplaced | Airboot, Crutches, NWB | vFAC | Ensure elevation advice given | |
# Talus |
Displaced | CT, BK backslab | Refer to Ortho on call | ||
# Mid-foot dislocation |
'Lisfranc' / crushed foot | CT, BK backslab | Refer to Ortho on call | Ensure not open, document NV status | |
# Metatarsals |
Multiple | Airboot, Crutches, heel WB | vFAC | Mid-foot dislocations (esp. if base of 2nd MT #). Ensure no chopart/lisfranc joint malalignment | |
# Metatarsals |
Single - not 5th MT base, especially stress # | Airboot, Crutches, heel WB | vFAC | Ensure no chopart/lisfranc joint malalignment | |
# Metatarsals |
Undisplaced 5th MT base | Airboot, Crutches, WBAT | Discharge / advice leaflet | Ensure no chopart/lisfranc joint malalignment | |
# Toe Phalanges |
#/dislocation | Reduce/buddy strap | Discharge / advice leaflet | ||
Open tendon injury |
Without skin loss | IV antibiotics, tetanus, splint, | Refer to Ortho on call | If skin loss, consult plastics on call | |
Open injury to toes/nail bed |
Including amputated toes | IV antibiotics, tetanus, splint | Refer to Ortho on call | If anticipated difficulty with wound closure, consult plastics on call, document NV status | |
Palpable lower limb foreign body |
IV antibiotics, tetanus, splint | Refer to Ortho on call | If impalpable, patient Mx by EM team | ||
Injury/fracture |
Subcategory |
Initial treatment |
Follow-up |
Beware/please document |
C-Spine fracture |
Refer to neurosurgical on call | |||
T-Spine fracture |
Stable/no neurology | CT scan | Fracture clinic | Document ortho on call team happy it is a stable injury and no neurology |
T-Spine fracture |
Unstable/neurology | CT scan. Refer to ortho team on call | ||
L-Spine fracture |
Stable/no neurology | CT scan | Fracture clinic | Document ortho on call team happy it is a stable injury and no neurology |
L-Spine fracture |
Unstable/neurology | CT scan. Refer to ortho team on call | ||
Spine sprains/whiplash injuries |
Do not refer to # clinic, GP to refer to elective service | |||
Non traumatic back pain |
No motor neurology or cauda equine | Consider/exclude infection. Do not refer to # clinic. GP to refer to elective service | ||
Non traumatic neck pain |
With neurology | Refer to neurosurgical on call | ||
Cauda Equina |
Refer to neurosurgical on call | |||
Injury/fracture |
Subcategory |
Initial treatment |
Follow-up |
Beware/please document |
Any fracture requiring surgery |
Upper limb & lower limb | Refer to ortho team on call | Combined care with orthogeriatric team | Medical consult for non-mechanical fall |
Complex fracture but not requiring surgery |
Upper limb & lower limb | Refer to ortho team on call | Combined care with orthogeriatric team | Medical consult for non-mechanical fall |
Simple fracture not requiring surgery |
Upper limb & lower limb | Admit under medical team/ transfer to geriatric service post call | Geriatric team | Ortho consult for follow up |
Pubic rami fractures |
Lower Limb | Admit under medical team/ transfer to geriatric service post call | Geriatric team | Ortho consult for follow up |
Sacral insufficiency fracture |
Lower Limb | Admit under medical team/ transfer to geriatric service post call | Geriatric team | Ortho consult for follow up |
Stable vertebral osteoporotic fractures |
Spine | Admit under medical team/ transfer to geriatric service post call | Geriatric team | Ortho consult for follow up |
Humeral /elbow non surgery |
Upper limb | Admit under medical team/ transfer to geriatric service post call | Geriatric team | Ortho consult for follow up |
Lower limb pain |
Unable to weight bear, no fracture | Admit under medical team/ transfer to geriatric service post call | Geriatric team | Ortho consult for follow up |