RHC Practical Fracture Management Guidance for use during COVID-19 crisis

What's New

Revised 21/05/20 to include new Virtual Fracture Clinic (VFC) pathway

NOTE: This guideline is for use during the COVID-19 outbreak and supersedes previous fracture management guidance for RHC

  • 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. If treating non-operatively windowed casts may be used.

***If there is any uncertainty over specific fracture definitions or management of the injury then contact RHC orthopaedic registrar.***

For all admissions document COVID status as per symptoms or known contact with symptomatic relative

 

Upper Limb

 

Diagnosis

 

Management

Follow up

Parental advice

Clavicle fracture

 

Broad arm sling/polysling

 

Nil
(*except for adolescent patients with significant deformity of skin compromise – VFC*)

Advice leaflet exists

AC joint disruption

 

Broad arm sling

Physio referral for telephone consultation in 10 days

 

Shoulder soft tissue injury

 

Broad arm sling

Physio referral for telephone consultation in 10-14 days

Gentle mobilisation as able

Shoulder dislocation

 

Reduction in ED or MIU, polysling

Physio referral for phone consultation in 10-14 days

Start gentle mobilisation at 10 days. Physio referral to Orthopaedics if any concerns.

Humeral Fracture

Proximal

Collar and cuff

VFC

Analgesia, advise to sleep inclined at about 45 degrees

 

 

Shaft

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

VFC

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

Elbows

 

 

 

 

 Elbow dislocation

 

Reduce and apply backslab and provide collar and cuff;

Call for Ortho assistance if not reducible.

VFC

 

Elbow Injury

 

Effusion, posterior fat pad; no definite fracture seen

Collar and cuff

Nil;
Fracture clinic not necessary

Mobilisation advice as able.

Supracondylar Humeral Fracture

 

 

Gartland 1
Undisplaced

Collar and cuff

(backslab only if necessary for pain relief)

Nil;
Fracture clinic not necessary

Analgesia, gentle mobilisation after 3 weeks (may be asked to remove slab at home after 3 weeks)

Gartland 2
Minimally displaced

Apply backslab at more than 90 degrees of flexion and repeat Xray

VFC

Analgesia, may be advised to remove backslab at 3 weeks and mobilise

Gartland 3+
Markedly displaced

Document neurovascular assessment.

Call Ortho.

Post-op follow-up for wire removal at 3 weeks

Give analgesia before attending for wire removal

Lateral condyle fracture

Undisplaced

Backslab

VFC

Family may be asked to remove backslab after 5 weeks 

Displaced

Refer to Orthopaedics for admission and fixation.

Post-op management via face to face clinic

 

Medial Epicondyle Fracture

Displaced/undisplaced

Check Ulnar nerve; if intact, and no associated elbow joint dislocation treat non-operatively in collar and cuff

VFC

Likely gentle mobilisation after 2-3 weeks.

Radial Neck Fracture

Undisplaced, angulated <25 degrees, not involving joint surface

 

Collar and cuff

 

VFC

Mobilise as pain allows, discard sling after 14 days

Angulation, displacement  or intra-articular

Discuss with Orthopaedics

 

Admission or face-to-face Fracture attendance

As per fracture clinic advice

 

Forearm/Wrist Fractures

Look for Galeazzi/Monteggia patterns

If present refer to Orthopaedics for admission and fixation

Follow up as per operative instructions

 

Forearm shaft

 

 

No Clinical Deformity

 

Well-fitting above elbow backslab, complete with soft cast

VFC

Family may be asked to remove cast at 6 weeks

Clinical deformity

 

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

Follow-up via face-to-face fracture clinic as per post manipulation instructions

 

 

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 3 weeks

 

No follow-up

Parents advised to remove splint in 3 weeks

Displaced

Refer Orthopaedics. Consider manipulation under Entonox or Ketamine if appropriate.
May require admission for operative management.

Follow-up via face-to-face fracture clinic as per post manipulation instructions

 

Wrist: Physeal injury

 

Undisplaced or minimally displaced

Backslab or removable splint

No follow-up

Parents to remove backslab or splint at 4 weeks; no falls for another 3 weeks

Displaced

Refer Orthopaedics. Consider manipulation under Entonox or Ketamine if appropriate.
May require admission for operative management.

Follow-up via face-to-face fracture clinic as per post manipulation instructions

 

Scaphoid (Suspected>10 years)

Clinical

Wrist splint

*May be booked onto face-to-face clinic in 9-12 days directly from ED*

May require repeat imaging

Lower Limb

Diagnosis

 

Management

Follow up

Parental advice

Hip

SCFE

Refer to Orthopaedics for admission and fixation

As per Consultant operative plan

 

Femur

Neck

Refer Orthopaedics for likely fixation

As per Consultant operative plan

 

Shaft

 

Femoral nerve block, Thomas splint; Refer Orthopaedics for admission

<7 years hip spica application

>7 years fixation

As per Consultant operative plan

Family may need spica advice

Distal femur

Undisplaced: plaster

Displaced: Refer Orthopaedics for admission and fixation

Undisplaced: VFC

Displaced: As per Consultant operative plan

 

Knee

Intra-articular fracture

Refer Orthopaedics - may need admission for imaging and/or fixation

As per Consultant operative plan

 

Small effusion, weight bearing, no fracture

Soft tissue advice

Refer directly to Physio

 

Likely telephone physio consultation

Effusion, non weight bearing +/- fracture

Knee splint

VFC

May need face-to-face review and further imaging

Patella dislocation

Reduce

Physio referral, no fracture clinic follow-up

Likely telephone consultation with physio

Tibia

 

 

 

 

 

 

 

Undisplaced shaft

Well-fitting long leg cast and supply crutches (may need admission for physio)

VFC

Elevate; To return if pain increases

Displaced shaft +/- fibula fracture

 

Refer Orthopaedics. Consider manipulation under Entonox or Ketamine if appropriate. 

May require admission for operative management.

As per post-reduction guidance

 

Toddler fracture (clinical or fracture seen on xray)

 

Walking boot or if none small enough apply backslab. Direct discharge from ED

Nil

Family to remove boot at 3 weeks and advise that child may have odd gait/limp for 6 weeks

Isolated fibular shaft fracture

 

 

Symptomatic treatment and walking boot. Direct discharge from ED

Nil

Advice re analgesia. Discard boot at 4 weeks

Ankle

 

Ankle sprain

 

Direct discharge from ED

Nil

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

Distal fibula fracture

Walking boot and discharge from ED

Opt in physio at 4 weeks

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

Undisplaced distal tibia fracture

Walking boot and crutches (non or partial weight-bearing)

VFC

Likely to be advised to remove boot at home and mobilise as able

Any displaced distal tibia growth plate injury

Refer Orthopaedics. Consider manipulation under Entonox or Ketamine if appropriate.
May require admission for operative management.

As per post-reduction advice

 

Foot
Metatarsals

 

 

 

5th metatarsal Jones fracture in adolescent

Walking boot 

VFC

 

Base of 5th metatarsal avulsion fracture

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 

Nil if under 10 yrs of age.

VFC if > 10 yrs of age.

Weight bear as able in walking boot for 2 weeks and then trainer for 2 weeks

Multiple displaced metatarsal shaft fractures

Backslab
Discuss with orthopaedics if gross swelling

VFC

 

Midfoot

Lisfranc injury (unstable; swelling+)

 

Refer Orthopaedics.
May require admission for operative management.

As per operative instructions.

May result in long term stiffness

Calcaneum

 

 

 

 

 

Undisplaced

If undisplaced, walking boot for 4 weeks

Assess for other injuries.

VFC

 

Displaced

Refer Orthopaedics : May need admission for further imaging/fixation

 

Risk of long term pain and stiffness

Great toe

 

No deformity

Symptomatic treatment

Nil

Mobilise as able, may have 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

No deformity

No x-ray needed, buddy strap for comfort

Nil

Mobilise as able, may have symptoms for up to 6/52

Clinical deformity

X-ray, reduce as needed and buddy strap

Nil

Mobilise as able, may have symptoms for up to 6/52

Specific patient injury pathways for use during the COVID-19 (coronavirus) outbreak
  1. Toddler fractures (no fracture seen – clinically suspected): Patients to be put in a walking boot as usual. Advice leaflet to be given to advise removal of boot in 3 weeks and only then if not weight bearing after a further week they should contact the ED secretary who will book onto the next VFC
  2. 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
  3. Simple metatarsal shaft fractures or base of metatarsal fractures in patients under 10 years: Do not require follow-up. Please put on walking boot and give advice leaflet to parents. For >10 yr olds please refer for VFC follow up.
  4. Clavicle fractures: These do not require fracture clinic follow up. Please give appropriate advice leaflet.
  5. Buckle fractures: Apply splint (not cast) and discharge with advice leaflet. Not for fracture clinic follow up
How to apply soft casts : videos

RHCG ED upper limb soft cast application


RHCG ED lower limb soft cast application

Editorial Information

Last reviewed: 21 May 2020

Next review: 21 May 2021

Author(s): Miss Claire Murnaghan, Paediatric Orthopaedic Surgeon