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Orthopedic Manager

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-----  Upper Limbs  -----

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Scapula - glenoid neck Fracture, nondisplaced, non-angulated

True AP, Scapular Y, and Axillary Lateral views

Refer (3-7d)

Sling

A/W: Thoracic injuries, brachial plexus injury

Often need CT scan to evaluate chest injuries and extent of fracture

 

Scapula - glenoid neck Fracture; angulated>40, displaced >1cm

True AP, Scapular Y, and Axillary Lateral views

Consult(or referral 1- 3d)   

 

Scapula - glenoid lip

True AP, Scapular Y, and Axillary Lateral views

Consult (or referral 1- 3d)  

large lip fracture is often assoc with subluxation or partial dislocation of the humerus

 

Scapula - body

True AP, Scapular Y, and Axillary Lateral views

Consult (or referral 1- 3d)

A/W: Thoracic injuries, brachial plexus injury

Often treated conservatively

 

Clavicle Fracture, nondisplaced

Refer (5-7d)

Sling

A/W: Pneumothorax; subclavian artery and brachial plexus injury rare

Medial clavicle fracture need eval for mediastinal injuries

 

Clavicle Fracture, displaced, neurovasculer injury, impending skin compromised

Consult

A/W: Pneumothorax; subclavian artery and brachial plexus injury rare

May need ORIF for cosmesis, heavy labourers, high-level athletes

 

Clavicle AC separation - Type I: AC tender, XR - no change

Refer (3-7d)

Sling

Type I: XR - no change; AC ligament strain.

 

Clavicle AC separation - Type II: XR:+/- clavicle elevation; AC widened;

Refer (3-7d)

Sling

AC ligament disruption but coraco-clavicular intact

 

Clavicle AC separation - Type III: XR -distal clavicle elevated above acromion;

Refer (3-7d)

Sling

possibly operative disruption of AC and coracoclavicular ligaments and deltoid and trapezius insertions

 

Clavicle AC separation - Type IV: XR -distal clavicle displaced posteriorly

Consult (or referral 1-3d)

Sling

Rare

 

Clavicle AC separation - Type V: XR:>100% increase in coracoclavicular space

Consult

Sling  

 

Type VI: XR - clavicle under coracoid

Consult

A/W: Brachial plexus injury 

 

Proximal humerus Two-part = 1 fragment +

a) surgical neck

b) greater tuberosity

c) lesser tuberosity Fragment is angulated >45 or displaced or displaced

>1cm If no

displacement, it is 1 part fracture.

True AP, Scapular Y, and Axillary views

Refer (1-5 days) / Consult if displaced, dislocated or neurovasc probs

Sling

A/W: Axillary n. injuries most common but musculocutaneous n, brachial plexus, median n may be present Anterior or posterior shoulder dislocation, rotator cuff tear possible Check shoulder abduction (axillary), elbow flexion, supination (msc n.), wrist extensor (radial n), check “OK” pincher (ulnar n), thumb opposition, finger flexion (median n)

Note: Surgical neck most common, lesser tuberosity fracture uncommon. Get axillary X-ray. May need surgery if >5-10mm displacement, or if associated with anterior dislocation not able to be reduced. Sometimes reducing the dislocation will repair the displacement Most heal well except for anatomic neck fracture which are predisposed to avascular necrosis

 

Proximal Humerus Three-part = 2 fragments + humerus

True AP, Scapular Y, and Axillary views

Refer (1-5 days) / Consult if displaced, dislocated or neurovasc probs

Sling

See 2 part above

Greater tub humerus;+ surgical neck most common; usually humeral head remains in contact with glenoid

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Proximal Humerus Four part = 3 displaced fragments + humerus

True AP, Scapular Y, and Axillary views

Refer (1-5 days) / Consult if displaced, dislocated or neurovasc probs

Sling

See 2 part above

A/W: Often associated with dislocation

Difficult to treat and poorest result, get axillary X-ray

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Middle or distal humerus Fracture, including supracondylar or epicondylar Fracture

Consult

A/W: Brachial artery, nerve injury 

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Biceps tendon rupture (distal)

Referral (5-7 days)

Sling with the elbow at 90°

Hook test

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Triceps tendon rupture

Consult (referral 5-7 days)

Posterior splint or sling

A/W: Compartment syndrome, radial head fracture

Palpable depression prox to olecranon; may have intact extension; rare injury

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Olecranon Fracture, nondisplaced

Referral (1-3 days)

Sling or long arm posterior splint with the elbow flexed and forearm neutral

A/W: Ulnar n. injury, triceps mechanism, radial head fracture, Monteggia

All fractures are intra- articular, may treat conservatively

 

Olecranon Fracture displaced

Consult

A/W: Ulnar n. injury, triceps mechanism, radial head fracture, Monteggia

ORIF

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Capitellar Fracture

Consult

A/W: Compartment syndrome

May need CT to delineate injury; often require ORIF or arthroscopy

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Coronoid Fracture

Referral (1-3 days)

Posterior splint with the elbow at 90°

A/W: Radial head fracture

Often need ORIF; may need CT scan

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Radial Head Fracture Nondisplaced

AP and lateral of the elbow; radio-capitellar view

Referral (1-3 days)

Sling or posterior splint

Early ROM recommend ed; consider “radial head” view

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Radial Head Fracture, displaced or comminuted

AP and lateral of the elbow; radio-capitellar view

Consult (or refer 1-3 days)

A/W: Posterior splint

Distal radioulnar joint disruption, capitellum fracture

consider “radial head” view

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Radial head Fracture, dislocation of DRUJ (Essex- Lopresti fracture)

Consult

Posterior splint

Needs ORIF

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Radial Head dislocation, Ulna Fracture prox third (Monteggia)

Consult

Posterior splint

A/W: Brachial a., median or radial n. injury

Classified by Bado Type (depending on how radial head dislocates, usually anterior), ORIF typical

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Ulna, shaft Fracture middle ⅓ nondisplaced (<10° angulation, <50% displacement)

Referral (3-5 days)

Sugar tong Splint

A/W: Distal radioulnar joint injury

Usually due to direct blow

 

Ulna, shaft Fracture middle ⅓ displaced (>10° angulation, >50% displacement)

Consult (or referral 1-3 days)

Sugar tong Splint

A/W: Injury to radioulnar joint, radial n. injury

ORIF

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Ulna, shaft Fracture, proximal ⅓

Consult (or referral 1-3 days)

Sugar tong Splint

A/W: Injury to radioulnar joint

ORIF even for nondisplaced

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Ulna, shaft Fracture, distal ⅓

Consult (or referral 1-3 days)

Sugar tong Splint

A/W: Injury to radioulnar joint

Usually ORIF

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Radial Shaft, nondisplaced Fracture isolated

Referral

Sugar tong Splint

A/W: Injury to radioulnar joint, or ulna

Rare injury

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Radius ulna Fracture, 2 bone forearm fx

Consult

A/W: Compartment syndrome

ORIF

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Radial shaft, distal third, disruption Radial-ulnar joint (Galeazzi)

Consult

Signs of DRUJ Shortening of the radius by 5 mm, fracture of the base of the ulnar styloid, widening of DRUJ space by 2 mm 

ORIF

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Radial head dislocation, ulna Fracture (Galeazzi)

Consult

A/W: Brachial a. injury, median, radial n. injury 

 

Distal radius fracture (Colles), nondisplaced

Referral

Sugar tong splint

A/W: Median n. injury, ulnar styloid fracture

Malunion not uncommon

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Distal Radius Fracture (Colles), angulated or dorsal displacement

Consult (vs reduction and referral 1-3 days)

Sugar tong Splint

A/W: Median n. injury, ulnar styloid fracture

Reduction criteria:

• intra- articular step- off>1mm

• radial inclination< 15°

• volar tilt<neutral

• shortening >2mm

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Distal Radius Fracture(Smith), volar displacement

Consult

A/W: Median n. injury 

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Ulnar styloid Fracture

Referral (5-7 days)

Sugar tong splint

Triangular fibrocartilage complex of the wrist

Styloid base fracture may require pinning.

 

 

Scaphoid Fracture, Suspected or nondisplaced

AP and lateral views; scaphoid view

Referral (1-3 days)

Thumb Spica

A/W: AVN, non-union

Document Snuffbox tenderness on all wrist exams

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Scaphoid fracture displaced > 1mm or dislocated

AP and lateral views; scaphoid view

Consult (or referral 1-3 days)

Thumb Spica

A/W: Associated ligamentous injury, fracture

Most common wrist fx; AVN, non-union are complications

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Lunate Fracture

Referral

Sugar Tong

A/W: Associated ligamentous injury, scapholunate dissociation, scaphoid, distal radius fracture

Tender dorsum of wrist distal to Lister's tubercle. CT scan if high suspicion. All fractures high risk for osteonecrosis

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Lunate dislocation

Consult

Volar Splint or sugar tong

A/W: Can cause acute carpal tunnel syndrome

Capitate pushes back on the lunate Spilled teacup on the lateral film

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Perilunate dislocation

Consult

Volar Splint or sugar tong

Capitate is displaced dorsal to the lunate

 

Hamate Fracture

Referral (3-5 days)

Volar splint

A/W: Ulnar n. and artery

The hook of hamate pull test, “carpal tunnel” views or CT scan if high suspicion

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Capitate Fracture

Referral (3-5 days)

Sugar Tong

Associated ligamentous injury, scaphoid fx,

Isolated fracture rare, CT scan if high suspicion; Scaphocapitate syndrome

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Trapezium Fracture

Referral (3-5 days)

Thumb Spica

A/W: Distal radius, scaphoid, prox 1st MCP fracture-dislocation

Pain making “OK” sign; CT scan if high suspicion; treated with short -arm thumb spica

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Trapezoid Fracture

Referral (3-5 days)

Volar splint or sugar tong splint

A/W: Associated ligamentous injury, other assoc cuboid fracture

Tender at 2nd MC base, CT scan if high suspicion;

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Triquetrium Fracture

Referral (3-5 days)

Volar Splint or sugar tong splint

A/W: Associated ligamentous injury, triangular fibrocartilage complex

Midbody or chip fracture; Injury or pain to the ulnar aspect of the wrist; CT scan if high suspicion; displaced fracture may need ORIF

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Pisiform Fracture

Referral (5-7days)

Volar Splint or sugar tong splint

Sesamoid bone inside flex. carpi ulnaris; tender at hypothenar eminence

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Metacarpal Fracture base, Thumb, intra- articular,(Bennett), nondisplaced

Consider oblique films

Refer (1-3d)

Thumb spica

A/W: Ligament injury

ORIF

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Metacarpal Fracture base, Thumb, intra- articular,(Bennett), displaced

Consider oblique films

Consult

A/W: Ligament injury

ORIF

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Metacarpal Fracture base, Thumb, intra- articular, comminuted T or Y (Rolandos) 

Consider oblique films

Consult

A/W: Ligament injury

ORIF

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Metacarpal Fracture, shaft, thumb

Consider oblique films

Consult   

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Thumb, RCL/UCL injury

Refer (5-7d)

Thumb spica

If complete, needs ORIF, or thumb spica cast if incomplete

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MCP, dislocation, thumb, no Fracture

Consult

Thumb spica

Wrist and MCP joint flexed, and gentle pressure applied to the volar surface of the proximal phalanx as it is brought into extension.

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MCP, dislocation, Fingers 2nd-5th No Fracture

Referral (Consult if unable to reduce.)

Buddy tape fingers

All hand injuries should be evaluated for fight bite 

To reduce, flex wrist to relax flexor tendons, initial MCP hyperextension then dorsal pressure on proximal phalanx over MCP

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Metacarpal Base Fracture, 2nd- 5th, Nondisplaced and no intra- articular involvement

Consider oblique films

Referral (1-5 days)

Dorsal-volar splint with wrist in 30° extension, MCP joints free

A/W: Carpal fractures, ulnar n. injury (4th, 5th fingers)

Continue immobilization for 3-4 wks; fracture of 5th base usually need ORIF

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Metacarpal Base Fracture, 2nd- 5th, Displaced Extra-articular (angulation >30 degrees, shortening >4mm, any rotational deformity or intra-articular involvement

Consider oblique films

Consult (or referral 1-3 days)

Dorsal-volar splint with wrist in 30° extension, MCP joints free

A/W: Carpal fractures, ulnar n. injury (4th, 5th fingers)

Reduction needed if >2 mm of articular surface displacement or significant angular deformity or dislocation of the CMC joint, esp of 5th MC (reverse Bennett)

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Metacarpal Shaft Fracture, 2nd- 5th, nondisplaced

Consider oblique films

Referral (1-3 days)

Ulnar or radial gutter

Consult if >1 metacarpal shaft fracture

Acceptable angulation:

• 2nd & 3rd, none;

• 4th <10°,

• 5th < 20°

splint with wrist in 20-30° extension, MCP 70-90° flexion, slight flexion of PIP (or dorsal- volar splint)

 

Metacarpal Shaft Fracture, 2nd- 5th, displaced, rotated, shortened or angulated

Consider oblique films

Consult

Dorsal-volar splint Long oblique frxs

most often need ORIF, Most shaft fractures best-treated non-op, reduction technique*

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Metacarpal Neck Fracture, 2nd- 5th, nondisplaced

Consider oblique films

Referral (1-5d)

Ulnar or radial gutter splint with wrist in 20-30° extension, MCP 70-90° flexion, slight flexion of PIP

Acceptable angulation;

2nd-& 3rd <10-15°,

4th <20-30°,

5th <30°

normal MC head to neck angle =15° so measure then subtract

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Metacarpal Neck Fracture, 2nd- 5th, angulated, shortened >4mm, rotated >5°, severely comminuted

Consider oblique films

Consult

Ulnar or radial gutter splint with wrist in 20-30° extension, MCP 70-90° flexion, slight flexion of PIP

Use hematoma block to reduce, may need ORIF; healing time 4-6wks

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Metacarpal Head Fracture, 2nd- 5th, Nondisplaced

Consider oblique films

Referral (1-3d; consult if fight bite)

Ulnar gutter splint or dorsal- volar splint

Usually from a direct blow, a splint for 3 wks

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Metacarpal Head Fracture, 2nd- 5th, Displaced >1-2mm

Consider oblique films

Consult (or referral 1-3 days)

Ulnar gutter splint or dorsal- volar splint Needs ORIF

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Proximal Phalanx Fracture, Thumb, nondisplaced

Refer (1-3d)

Thumb spica

A/W: Ligament injury 

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Proximal Phalanx Fracture, Thumb, displaced or angulated

Consult

Thumb spica

Ligament injury 

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Proximal Phalanx Fracture, Base, 2nd-5th, nondisplaced, unicondylar Fracture <25% articular surface

Referral (1-3d)

Buddy tape or ulnar/radial gutter splint with wrist in 20-30° extension, MCP in 70-90° flexion, PIP/DIP 5-10° flexion

A/W: Extensor/flexor tendon injury; digital n. 

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Proximal Phalanx Fracture, Base, 2nd-5th, displaced

Consult (or refer if able to reduce)

Ulnar/radial gutter splint with wrist in 20-30° extension, MCP in 70-90° flexion, PIP/DIP 5-10° flexion

A/W: Extensor/flexor tendon injury; digital n.

Often need ORIF

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Proximal Phalanx Fracture, Shaft, 2nd-5th, nondisplaced, <20 angulation, no clinical deformity

Referral (1-3 days)

Buddy tape or ulnar/radial gutter splint with wrist in 20-30° extension, MCP in 70-90° flexion, PIP/DIP 5-10° flexion

A/W: Extensor/flexor tendon injury; digital n. 

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Proximal Phalanx Fracture, Shaft, 2nd-5th, transverse, spiral, oblique or intra- articular

Consult (or refer if able to reduce)

Ulnar/radial gutter splint with wrist in 20-30° extension, MCP in 70-90° flexion, PIP/DIP 5-10° flexion

A/W: Extensor/flexor tendon injury; digital n.

No degree of rotation is acceptable

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Proximal Phalanx Fracture, Neck, 2nd-5th, nondisplaced

Refer (1-3 days)

Ulnar/radial gutter splint with wrist in 20-30° extension, MCP in 70-90° flexion, PIP/DIP 5-10° flexion

A/W: Extensor/flexor tendon injury; digital n. 

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Proximal Phalanx Fracture, Neck, 2nd-5th, displaced

Consult

Ulnar/radial gutter splint with wrist in 20-30° extension, MCP in 70-90° flexion, PIP/DIP 5-10° flexion

A/W: Extensor/flexor tendon injury; digital n. 

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PIP Dislocation

Referral (consult if unable< to reduce)

Splint in extension

A/W: Extensor/flexor tendon injury; digital n. injury or injury to central slip (check for pain with extension after reduction)

May have clinically inconsequential avulsion fragment of prox or middle phalanx; flex wrist for reduction

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Middle Phalanx Fracture, nondisplaced

Referral (1-3d)

Buddy tape or aluminum

A/W: Extensor/flexor tendon injury 

splint with a finger in slight flexion

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Middle Phalanx Fracture, displaced, angulated

Consult (or refer is able to reduce)

Ulnar/radial gutter splint with wrist in 20-30° extension, MCP in 70-90° flexion, PIP/DIP 5-10° flexion or dorsal splint with buddy taping

A/W: Extensor/flexor tendon injury; digital n., Boutonniere deformity 

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Boutonniere deformity

Referral (1-3 days)

splint PIP in full extension, the DIP should not be splinted

Splint x5-6 weeks, surgery if non-op RX fails. Use Elson’s test**

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DIP Dislocation

Referral

Aluminum splint across volar DIP

A/W: Flexor tendon injury common

May have assoc avulsion fracture, reduce splint and refer

 

Mallet finger

Referral (1-5d)

Splint across DIP, volar aspect

Associated middle or distal fracture

Immobilize in slight hyperextension, often for 6-10wks

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Jersey finger (closed flexor tendon injury)

Consult (or refer 1-3 days)

Aluminum splint with PIP/DIP slightly flexed

Avulsion fractures

Four types based on the degree of tendon retraction; all require surgery

 

Distal Phalanx Fracture, nondisplaced

Follow up with PCP

Volar aluminum splint with DIP in slight extension; allow PIP ROM

A/W: Nailbed lacerations, subungal hematomas

Splint for3-4 wks

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Distal Phalanx Fracture involves more than just tuft, intra- articular Fracture or assoc tendon laceration

Referral (1-5d)

Volar aluminum splint with DIP in slight extension or hairpin splint

A/W: Nailbed lacerations, subungal hematomas, flexor tendon injuries

Do not try to reduce comminuted fracture, prophylactic antibiotics for open fractures is controversial (Keflex x7d is reasonable). Malunion not uncommon

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SPECIAL NOTE:

• Normal 2 point discrimination is 4-5mm.    

• All hand injuries should be evaluated for “fight bite”.

• All open injuries need consult except for distal phalanx Fracture. Complications are nonunion, malunion.

 

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-----  Lower Limbs  -----

 

Patella Fracture, non-displaced or vertical Fracture with intact extensor mechanism

Consult

Knee immobilizer

Perform straight leg raise to assess intact extensor mechanism

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Patella Fracture, displaced or transverse Fracture with loss of extensor mechanism

Referral (<5d)

Knee immobilizer Limit weight-bearing

Most need ORIF

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Patella dislocation

Referral (7d)

Knee immobilizer for comfort for a short time

A/W: Patellar or quadriceps tendon rupture

Reduce then immobilizer

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Quadriceps Tendon Rupture

Consult if a complete rupture

Knee immobilizer

A/W: Intra-articular knee injuries

Surgery for complete rupture, immobilizer for partial tendon rupture for 4-6wks

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Patellar Tendon Rupture

Consult if a complete rupture

Knee immobilizer

Surgery for complete rupture, immobilizer for partial tendon rupture for 4-6wks

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Tibial Plateau Fracture

Consult

Compartment syndrome, peroneal n. injury, popliteal a. injury

Obtain CT scan of the knee; probable admission

 

Tibial Spine Fracture, non-displaced and stable knee

Referral (3-5d)

Knee immobilizer

A/W: Ligamentous injury 

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Tibial Spine Fracture, complete avulsion, displaced or unstable knee

Consult or next day referral

Knee immobilizer

A/W: Ligamentous injury

Usually needs ORIF

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Tibial Tubercle Fracture, nondisplaced

Consult

Knee immobilizer  

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Tibial Tubercle Fracture, displaced or avulsed

Consult

Knee immobilizer

A/W: Anterior compartment syndrome, recurrent ant tibial a. injury

Usually needs ORIF

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Tibial Shaft Fracture

Consult

A/W: Compartment syndrome, neurovascular injuries

Needs ORIF

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Fibula Fracture, proximal

Referral or consult

Knee immobilizer

A/W: Peroneal n. anterior tibial a. injury, ligamentous knee injury, occult knee dislocation; assess ankle (Maisonneuve fracture)

May be isolated or associated with significant injuries, CT scan not unreasonable

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Fibula Shaft Fracture

Referral (5-7d)

Ace wrap or knee immobilizer

Immobilize for comfort, weight-bearing as tolerated

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Fibula Fracture, Distal, Weber Type A, min or nondisplaced or avulsion Fracture

Gravity Stress Views

Referral (5-7d)

Walker boot

If medial malleolar tenderness may need stress views

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Fibula Fracture, Distal, Weber Type A, displaced

Consult

Walker boot

May need ORIF or reduction

 

Fibula Fracture, Distal, Weber Type B, min or nondisplaced Fracture

Gravity Stress Views

Referral (3-5d)

Cadillac

May need ORIF; gravity views helpful

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Fibula Fracture, Distal, Weber Type C

Consult

Cadillac

May need ORIF

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Medial malleolar Fracture, non-displaced or tip avulsions

Referral (3-5d)

Cadillac

Ortho will measure talocrural angle

 

Medial malleolar Fracture, displaced or talar. shift

Consult

Cadillac

A/W: Prox fibula fracture (Maisonneuve) , talus neck, cuboid fracture, deltoid ligament

Needs ORIF

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Bimalleolar Fracture with or w/o dislocation

Consult

Cadillac

Needs ORIF

 

Posterior Malleolar, <25% articular surface, isolated

Referral (3-5d)

Cadillac

Needs CT scan to accurately assess

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Posterior Malleolar, >25% articular surface, isolated

Consult

Cadillac

Needs ORIF

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Tibial Plafond Fracture

Consult

A/W: Compartment syndrome, lumbar, calcaneal, tibial fractures

Consider CT to assess vascular injuries; often needs to be admitted

 

Calcaneus Fracture

Consult

A/W: Vertebral fracture, other calcaneus, knee injuries

CT scan before the consult. Some small extra-articular fracture treated non-operatively

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Achilles tendon rupture

Referral (<5d)

Posterior splint with plantar flexion 

foot U/S may be helpful

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Peroneal Tendon Subluxation

Mortise view of the ankle

Referral (3-5d)

Cast with foot plantar flexion

May need MRI for diagnosis

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Talus, head, neck, body (lateral or posterior), non-displaced

Referral (3-5d)

Cadillac

Tender at the talonavicular joint; fracture may not be evident on x-ray

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Talus, with a displaced fragment >2mm

Canale View

Consult

Cadillac

A/W: Foot compartment syndrome is a theoretical concern, associated fractures

Canale view provides the best view of talar arch; CT scan if suspicion

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Subtalar dislocation

Consult

Cadillac

A/W: Foot compartment syndrome is a theoretical concern

Most are medial. Closed reduction with the knee flexed to relax gastroc,  then CT scan to assess the reduction

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Navicular Fracture, avulsion or tuberosity

Referral (3-5d)

Cadillac

A/W: Foot compartment syndrome is a theoretical concern

May need ORIF

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Navicular Fracture, body

Referral(3-5d)

Cadillac

A/W: Foot compartment syndrome is a theoretical concern

Isolated fractures are rare; consider CT scan

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Navicular Dislocation

Consult

A/W: Foot compartment syndrome is a theoretical concern

Usually needs ORIF

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Cuneiform Fracture, non-displaced

Referral(3-5d)

Posterior splint

A/W: Lisfranc injury

May need ORIF; Isolated fractures uncommon; consider CT scan

​

Cuneiform Fracture, displaced

Referral(3-5d)

Posterior splint

A/W: Lisfranc injury 

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Cuboid Fracture

Referral(3-5d)

Posterior splint

Lisfranc injury

Non-weight-bearing x4-6weeks. ORIF for comminuted fracture or 2mm joint surface disruption consider CT scan

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Lisfranc Injury

Consult

Foot compartment syndrome

Obtain weight-bearing views or CT scan. Flake fracture of 2nd MT indicative of Lisfranc injury

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1st metatarsal (MT) Fracture,non-displaced

Gravity stress

Referral(5-7d)

Hard sole shoe or walker boot

Obtain stress views

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1st MT Fracture displaced

Referral(<5d)

Posterior splint (non-weight-bearing)

May require ORIF

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1st MTP Fracture dislocation

Referral(7d)

Walker boot

Reduction then boot

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2nd-4th MT Fracture, min or non-displaced

Referral(5-7d)

Hard sole shoe or walker boot, depending on pts comfort

Isolated fractures depending on angulation may need ORIF, single fractures heal well

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2nd-4th MT Fracture, displaced or angulated or multiple

Referral (<5d)

Posterior splint Non-weight bearing

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5th MT Fracture, Zone 1, avulsion

Referral(5-7d)

Walker boot

A/W: Lateral malleolus fracture 

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5th MT Fracture, Zone 2, Jones Fracture

Referral(5-7d)

Posterior splint

May need a short leg cast for 6-8 weeks

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5th MT Fracture, Zone 3, proximal shaft Fracture

Referral(5-7d)

Posterior splint

May need ORIF

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Sesamoid bone Fracture  

Referral (7d)

Walker boot

May need sesamoidectomy

 

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-----  Dislocations  -----

 

Hip Dislocation

AP Pelvis (pre-reduction)

Consult

Abduction Pillow

A/W: Acetabular Fracture

Must ambulate prior to ED discharge if ambulatory prior to the injury

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Prosthetic Hip Dislocation

AP Pelvis (pre-reduction)

Consult

Abduction Pillow

A/W: Acetabular Fracture

Must ambulate prior to ED discharge if ambulatory prior to the injury

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Knee Dislocation

Perform ABIs, if normal (greater than .9); may not need CTA, but still a consideration for observation

Consult

Knee Immobilizer

A/W: Compartment Syndrome/Popliteal Artery Injury

Always Consult 

 

Prosthetic Knee Dislocation

Perform ABIs, if normal (greater than .9); may not need CTA, but still a consideration for observation

Consult

Knee Immobilizer

A/W: Compartment Syndrome/Popliteal Artery Injury

Always Consult

 

Elbow Dislocation

AP/ Lat Elbow Films

Referral for Simple (No associated fracture or nerve injury)

or Consult if Complex (associated fracture or neurapraxia) or difficulty reducing

Sling or Posterior Splint

Ulnar Nerve injury; Radial head or neck (5-10%), medial/lateral epicondyle avulsions (10%), those of the coronoid process (10%), and fractures of the distal radius, ulna, and proximal humerus (10%)

Consult if ulnar neurapraxia or difficulty reducing

 

Shoulder Dislocation (Anterior)Pre-reduction:

True AP, Scapular Y, and Axillary views

Consult for any associated fracture (e.g. Greater Tuberosity, Humeral Neck);

Consult NOT REQUIRED for uncomplicated Bankart or Hills-Sachs deformity;

Simple Dislocation Referral (5-7 d)

Sling

A/W: Bankart lesion, Hill-Sachs lesion, rotator cuff tear, or injury to the axillary nerve.

Consult for any associated fracture (e.g. Greater Tuberosity, Humeral Neck) or if difficulty reducing

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Shoulder Dislocation (Anterior) with Associated Humeral Neck FracturePre-reduction:

True AP, Scapular Y, and Axillary views

Consult

A/W: Bankart lesion, Hill-Sachs lesion, rotator cuff tear, or injury to the axillary nerve.

Likely an Operative Reduction to prevent worsening of the fracture

 

Shoulder Dislocation (Posterior)Pre-reduction:

True AP

Consult for any associated fracture (e.g. Greater Tuberosity, Humeral Neck);

Consult NOT REQUIRED for uncomplicated Bankart or Hills-Sachs deformity; Simple Dislocation Referral (5-7 d)

Sling

A/W: Bankart lesion, Hill-Sachs lesion, rotator cuff tear, or injury to the axillary nerve.

Consult for any associated fracture (e.g. Greater Tuberosity, Humeral Neck) or if difficulty reducing; Consider Seizure if mechanism uncertain

 

Shoulder Dislocation (Inferior)Pre-reduction:

True AP

Consult for any associated fracture (e.g. Greater Tuberosity, Humeral Neck);

Consult NOT REQUIRED for uncomplicated Bankart or Hills-Sachs deformity; Simple Dislocation Referral (5-7 d)

Sling

A/W: Greater tuberosity avulsion fractures and other associated fractures are of the glenoid, acromion, surgical neck, humeral head, and scapular body

Consult for any associated fracture (e.g. Greater Tuberosity, Humeral Neck) or if difficulty reducing

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