ACEM Fellowship
Fracture Quick Guide
Shoulder Girdle
| Sternoclavicular dislocation | |
| Anterior | Broad-arm sling and # clinic |
| Posterior | CT scan with angiogram, broad-arm sling and Ortho Consult for consideration of operative repair |
| Clavicle fractures | |
| Middle third | Broad-arm sling 4-8 weeks and # clinic Ortho Consult if skin tenting |
| Distal third | Broad-arm sling 4-8 weeks and # clinic Ortho consult if significant upward displacement |
| Proximal third | CT with angiogram + Ortho consult for ? ORIF |
| Acromioclavicular dislocation | |
| Type I/II/III (<25% – 100% elevation) | Early ROM, broad-arm sling 7-14 days and # clinic |
| Type IV/V/VI (posterior, >100% elevation or any depression | Ortho consult for ? ORIF |
| Acute rotator cuff rupture | Broad-arm sling and # clinic |
| Rupture of long-head biceps | Broad-arm sling and # clinic |
| Glenohumeral dislocation | |
| Anterior | Shoulder immobiliser 1 week # clinic if 1st time Ortho consult if large Bony Bankart for ? ORIF Physio referral |
| Posterior | Shoulder immobiliser in 15 degrees external rotation # clinic if 1st time Physio referral |
| Scapular fractures | |
| Non-displaced | CT for other injuries. Broad-arm sling and # clinic |
| Displaced or neck fractures | CT for other injuries. Broad-arm sling and Ortho consult for ? ORIF |
Humerus
| Proximal humerus | |
| Neer Group 1 – All fractures with minimal displacement/angulation | Broad-arm sling or collar-cuff (if traction desired) and # clinic |
| Neer Group 2 – Anatomical neck >1cm displaced | Broad-arm sling and Ortho consult for ? ORIF |
| Neer Group 3 – All displaced or severely angulated surgical neck fractures | Broad-arm sling or collar-cuff (if traction desired) and Ortho consult for ? ORIF |
| Neer Group 4 – Displaced greater tuberosity | Ortho consult for ? ORIF |
| Neer Group 5 – Displaced lesser tuberosity | Ortho consult for ? ORIF |
| Neer Group 6 – Fracture-dislocations | Ortho consult for ? ORIF If greater tuberosity only – treat as glenohumeral dislocation and obtain Ortho consult if remains greater tuberosity remains displaced post-reduction |
| Humeral shaft | |
| Undisplaced spiral | U plaster, collar and cuff and # clinic |
| Undisplaced transverse | Collar and cuff and # clinic |
| Displaced | Collar and cuff + U plaster and Ortho Consult |
Elbow
| Supracondylar/intercondylar fractures | |
| Undisplaced | Above elbow cast in flexion and mid-pronation. # clinic |
| Displaced | Reduce. Above elbow cast in flexion and mid-pronation. Ortho consult for ? ORIF |
| Lateral epicondyle | Above elbow cast in flexion and supination. # clinic. |
| Medial epicondyle | Above elbow cast in flexion and pronation. # clinic |
| Lateral condyle | |
| Undisplaced | Above elbow cast in flexion. # clinic. |
| Displaced | Ortho consult for ? ORIF |
| Trochlear | Above elbow cast. Otho consult for ? ORIF |
| Capitellum | Above elbow cast. Ortho consult for ? ORIF |
| Elbow dislocation | Reduce. Above elbow cast 90 degrees flexion and mid-pronation. # clinic. |
| Elbow fracture-dislocation | Reduce. Above-elbow cast 90 degrees flexion and mid-pronation. Ortho consult for ? ORIF |
| Olecranon | |
| Undisplaced | Above-elbow cast in 60 degrees flexion. # clinic |
| Displaced | Above-elbow cast in 60 degrees flexion. Ortho consult for ? ORIF |
| Coronoid | Above elbow cast in flexion and supination. Ortho consult for ? ORIF |
| Radial head | |
| Mason I – Undisplaced | Broad-arm sling. # clinic. |
| Mason II – Displaced | Above-elbow cast. Ortho consult for ? ORIF |
| Mason III – Comminuted | Above-elbow cast. Ortho consult for ? excision |
| Mason IV – Fracture with elbow dislocation | Reduce. Above-elbow cast. Ortho consult for ? ORIF |
| Radial neck | |
| <20 degrees angulation | Broad-arm sling. # clinic |
| >20 degrees angulation | Above-elbow cast. Ortho consult for ? ORIF |
Forearm
| Isolated ulna shaft (Nightstick) | |
| Stable (<50% displaced, <10 degrees angulation, distal 2/3 ulnar shaft) | Above-elbow cast in mid-pronatoin. # clinic. |
| Unstable | Above-elbow cast in mid-pronation. Ortho consult for ? ORIF |
| Radial shaft | Above-elbow cast in mid-pronation. Ortho consult for ? ORIF |
| Galeazzi – Displaced fracture of distal 1/3 of radius with DRUJ injury | Reduction. Above-elbow backslab in supination. Ortho consult for ORIF |
| Monteggia – Proximal 1/3 ulnar shaft fracture with proximal radial head dislocation | Reduction. Above-elbow backslab in supination. Ortho consult for ORIF |
Wrist
| Colles | |
| Stable – <20 degrees angulation, no intra-articular, not comminuted, not shortened | Charnley slab. # clinic. |
| Unstable | Reduce. Charnley slab. CT and Ortho consult for ? ORIF |
| Acceptable healed position | Dorsal tilt <5 degrees (aim volar tilt 11 degrees) <2mm radial shortening Radial inclination 15-25 degrees No dorsal displacement or radial shift |
| Smith’s (distal radius with volar angulation) | Above elbow slab in supination and dorsiflexion. Ortho consult for ? ORIF |
| Barton’s (dorsal or volar rim distal radius) | Above elbow slab in supination and dorsiflexion. Ortho consult for ? ORIF |
| Chauffer’s (Radial styloid) | |
| Undisplaced | Charnley slab in ulnar deviation, palmar flexion and full pronation. # clinic. |
| Displaced | Charnley slab in ulnar deviation, palmar flexion and full pronation. Ortho consult for ? ORIF |
| Die-punch – Lunate fossa depression on radius | Volar POSI. Ortho consult for ? ORIF |
| Ulnar styloid fracture | |
| Stable DRUJ | Ulnar gutter splint. # clinic. |
| Unstable DRUJ | Ulnar gutter splint. Ortho consult for ? ORIF |
Carpus
| Scaphoid | |
| Non-displaced | Scaphoid cast and # clinic |
| Displaced | Scaphoid cast. Hands consult for ? ORIF |
| Triquetrum | |
| Avulsion | POSI cast and # clinic |
| Displaced or associated dislocation | POSI cast and Hands consult for ? ORIF |
| Lunate | Thumb spica and # clinic. |
| Lunate/peri-lunate dislocation | Hand consult prior to reduction. Volar POSI in slight flexion. CT and Hands consult. |
| Trans-scaphoid dislocation | Reduce. Manage as for scaphoid fracture. CT and Hands consult for ORIF |
| Trapezium | |
| Non-displaced | Thumb spica and # clinic. |
| Displaced | Thumb spica and Hands consult for ? ORIF |
| Pisiform | Volar splint in 30 degrees flexion and ulnar deviation. # clinic. |
| Hamate | |
| Hook | Compression bandage and # clinic |
| Non-displaced body | POSI cast or wrist splint. # clinic |
| Displaced body | POSI cast and Hands consult for ? ORIF |
| Capitate | POSI cast and Hands consult for ? ORIF |
| Trapezoid | |
| Non-displaced | Thumb spica and # clinic |
| Displaced | Thumb spica and Ortho consult for ? ORIF |
Metacarpals
| Base of 1st metacarpal | |
| Extra-articular | Reduce if >30 degrees angulation. Thumb spica and # clinic |
| Rolando’s (intra-articular) | Thumb spica and Hands consult |
| Bennet’s (intra-articular fracture-dislocation) | Thumb spica and Hands consult |
| Metacarpal base fracture | Consider CT. Volar POSI and Hands consult for ORIF |
| Metacarpal shaft fracture | |
| Non-displaced | Volar POSI. # clinic. |
| Displaced | Volar POSI and Hands consult for ORIF |
| Metacarpal neck fractures | |
| Non-displaced | Volar POSI. # clinic. |
| Displaced | Reduce if: 2nd >10 degrees 3rd >20 degrees 4th >30 degrees 5th >40 degrees Any rotational deformity Volar POSI and # cinic |
| Metacarpal head fracture | Volar POSI and Hands consult |
Fingers
| MCP dislocation | Reduce – Flex wrist and apply pressure over dorsal surface of proximal phalanx. Volar POSI and # clinic |
| IP dislocation | |
| Dorsal/lateral | Reduce. Buddy strap or splint in slight flexion. # clinic. |
| Volar | Reduce. Splint in extension. # clinic |
| Fracture-dislocation | Hands consult. |
| CMC joint dislocation | Reduce. Thumb spica. Hands consult for assessment of stability and ? ORIF |
| Thumb MCP dislocation | Reduce. Thumb spica. Hands consult for ? ORIF. |
| Thumb IP dislocation | Reduce. Thumb spica. Hands consult for ? ORIF |
| Gamekeeper’s thumb (UCL tear) | Thumb spica and Hands consult for ? operative repair |
| Proximal and middle phalanx | |
| Non-displaced | Aluminium gelufoam splint or Buddy strap. # clinic. |
| Displaced – Extra-articular >10 degrees angulation – Intra-articular – >2mm shortening – Rotational deformity – Irreducible/unstable | Volar POSI and Hands consult for ? ORIF |
| Distal phalanx | |
| Extra-articular | Treat soft tissue injury. Splint. # clinic. |
| Intra-articular | Splint and Hands consult. |
| Mallet fracture <25% articular | Mallet splint (DIP extension). # clinic. |
| Mallet fracture >25 % articular | Mallet splint and Hands consult for ORIF |
Femur and knee
| Femur | Ortho admission for all Consider femoral nerve block and traction bed requirements |
| Knee | |
| Knee dislocation | Reduce. CT with angiography. Above knee backslab. Urgent Ortho consult +- Vascular |
| Quadriceps rupture | Richards splint, crutches, NWB. Ortho consult for planned repair |
| Patellar tendon rupture | Richards splint, crutches, NWB. Ortho consult for planned repair |
| Patella fracture | |
| Extensor mechanism intact | Richards splint. Partial WB. # clinic. |
| Extensor mechanism ruptured | Richards splint. Ortho consult for planned repair |
| Lateral patellar dislocation | Richards splint. Partial WB with crutches. # clinic. |
| Acute knee ligamentous injury | Richards splint. Crutches. Consider OPD MRI and # clinic. |
Tibia and Fibula
| Tibial plateau | |
| Shatzker I/II | ROM knee brace, NWB, crutches. Ortho consult for ? ORIF |
| Shatzker III/IV/V/VI | Above knee backslab. Ortho admission. |
| Tibial shaft | Above knee backslab. Ortho admission. Circulation obs for / compartment sx Acceptable reduction – >50% cortical contact – <10 degrees angulation AP and lateral – <5 degrees rotation |
| Fibular shaft | |
| Associated tibia fracture | Treast as for tibia |
| Isolated non-displaced | Short-leg backslab, NWB, crutches, # clinic |
| Displaced/spiral | Short-leg backslab. Ortho consult for ? ORIF |
Ankle
| Maissoneuve (ankle and proximal/mid-fibula) | Long leg cast and Ortho consult for ORIF |
| Pilon (tibial plafond) | Reduce, CT, short-leg cast and Ortho consult for ORIF |
| Triplane fracture | Reduce, CT, short-leg cast and Ortho consult for ORIF |
| Tillaux fracture | Reduce, CT, short-leg cast and Ortho consult for ORIF |
| Lateral ankle sprain | |
| Stable and can weight bear | RICE, WBAT, GP/physio |
| Stable and unable to weight bear | Moonboot, WBAT, crutches, GP/Physio |
| Unstable | Short-leg cast and # clinic |
| Medial ankle sprain without syndesmotic injury | Moonboot, WBAT, crutches, # clinic |
| Medial ankle sprain with syndesmotic injury | Short-leg cast, NWB, crutches, # clinic |
| Lateral malleolar fractures | |
| Minimally displaced avulsion <3mm | Moonboot, WBAt, crutches, # clinic |
| Displaced avulsion | Short-leg cast or Moonboot, NWB, crutches, # clinic |
| Weber A | Short-leg cast or Moonboot, NWB, crutches, # clinic |
| Weber B | Short-leg cast or Moonboot, NWB, crutches, # clinic |
| Weber C | Short-leg cast and Ortho consult for ORIF |
| Associated medial injury | Short-leg cast and Ortho consult for ORIF |
| Any displacement or talar shift | Reduce, short-leg cast and Ortho consult for ORIF |
| Medial malleolar fractures | |
| Isolated non-displaced | Short-leg cast, WBAT, # clinic |
| Displaced | Reduce, short-leg cast and Ortho consult for ORIF |
| Bimalleolar/trimalleolar/ankle dislocation | Reduce, CT, short-leg cast and Ortho consult for ORIF |
| Achilles rupture/tear | Shoe riser or POP equinus cast and # clinic |
Foot
| Calcaneus | |
| Avulsion | Short-leg cast, NWB, cruthces, # clinic |
| Body | Ortho consult for ? ORIF |
| Talus | |
| Undisplaced, osteochondral fracture of dome or posterior process | Short-leg slab, NWB, crutches and # clinic |
| Talar dome fracture | CT, Ortho consult for ? ORIF |
| Lateral process | CT, short-leg cast and # clinic |
| Displaced/head/neck/body | CT and Ortho consult for ORIF |
| Subtalar dislocation | Reduce, short-leg cast and Ortho consult for possible admission |
| Lisfranc | |
| Non-displaced | Short-leg cast, NWB, crutches, # clinic |
| Displaced | Reduce, short-leg cast and Ortho consult for ORIF |
| Navicular | |
| Non-displaced | Short-leg cast, NWB, crutches and # clinic |
| Displaced | Short-leg cast, NWB, Ortho consult for ORIF |
| Cuboid | |
| Non-displaced | Short-leg cast, NWB, crutches, # clinic |
| Displaced/comminuted | Short-leg cast, ortho consult for ORIF |
| Cuneiform | |
| Medial cuneiform | Short-leg cast, NWB, crutches, Ortho consult |
| Middle or lateral cuneiform | Short-leg cast, NWB, crutches, # clinic |
| 5th metatarsal | |
| Zone 1 (Pseudojones into proximal tubercle/metatarso-cuboid joint) | Moonboot, WBAT, # clinic |
| Zone 2 (Jones into 4/5th metatarsal joint) | Short-leg cast, NWB, crutches, # clinic |
| Zone 3 (Distal to 4th/5th metatarsal articulation) | Short-leg cast, NWB, crutches, # clinic |
| 2nd-4th metatarsal | |
| Isolated proximal | Short-leg cast and # clinic |
| Non-displaced isolated shaft | Moonboot, WBAT and # clinic |
| Displaced shaft >10 degrees dorsal/plantar | Short-leg cast, NWB, Ortho consult for ORIF |
| Multiple | Short-leg coast, NWB, Ortho consult for ORIF |
| 1st metatarsal | |
| Non-displaced | Moonboot, WBAT and # clinic |
| Displaced | Short-leg cast and Ortho consult for ORIF |
| Phalanges | Buddy strap, WBAT and # clinic or GP Consider surgical shoe for 1st toe |
Long arm backslab
Indications
- Peri-elbow fractures
- Smith’s
- Dual Radius + Ulna fractures
Steps:
- Position patient
- Prepare slab of 8 layers of 15cm wide POP at minimum
- Length – Middle of upper arm to just proximal to MCP joints
- Cut slits at elbow on either side to allow them to overlap
- Soft cotton roll applied with minimum 2 layer coverage, 50% overlap and no creases
- Position in 90 degrees flexion and neutral pronation
- Dip plaster in room temp water until bubbles cease then hold up and concertina back into hand
- Apply plaster and smooth out any creases (can apply bilateral elbow stirrups to strengthen if large/strong patient)
- Crepe bandage applied firmly (stretches with time)
- Ensure elbow held in position until dry
- Broad-arm cotton sling provided
Short-arm Charnley
Indication
- Colles’ fracture
Steps:
- Position patient
- Prepare slab of 8 layers of 15cm wide POP at minimum
- Length – Handbreadth from elbow crease to just proximal to MCP joints (use template below)
- Soft cotton roll applied with minimum 2 layer coverage, 50% overlap and no creases
- Dip plaster in room temp water until bubbles cease then hold up and concertina back into hand
- Apply plaster and smooth out any creases
- Crepe bandage applied firmly (stretches with time)
- Three-point immobilisation performed in slight ulnar deviation and palmarflexion (see image)
- Broad-arm cotton sling provided
*Note above should be printed on A4 to be used as template
Volar POSI
Indications
- All other wrist/carpal/metacarpal fractures
Steps:
- Position patient
- Prepare slab of 8 layers of 15cm wide POP at minimum
- Length – Handbreadth from elbow crease to just beyond fingertips
- Soft cotton roll applied with minimum 2 layer coverage, 50% overlap and no creases
- Dip plaster in room temp water until bubbles cease then hold up and concertina back into hand
- Apply plaster and smooth out any creases
- Crepe bandage applied firmly (stretches with time)
- Ensure MCP 70 degrees flexed and wrist 30 degrees dorsiflexed while setting
- Broad-arm cotton sling provided
Volar POSI (print on A4 for use as template)
Thumb spica
Indications
- Scaphoid/Lunate/Trapezium/Trapezoid
- Bennet’s/Rolando’s/Extra-articular 1st metacarpal
Steps:
- Position patient
- Prepare slab of 8 layers of 15cm wide POP at minimum
- Length – Midforearm to just proximal to thumb IP joint (see template below)
- Soft cotton roll applied with minimum 2 layer coverage, 50% overlap and no creases
- Dip plaster in room temp water until bubbles cease then hold up and concertina back into hand
- Apply plaster and smooth out any creases
- Crepe bandage applied firmly (stretches with time)
- Ensure thumbs up position
- Broad-arm cotton sling provided
Thumb spica (print on A4 page for use as template)
Ulnar gutter
Indications
- Ulnar styloid fracture
Steps:
- Position patient
- Prepare slab of 8 layers of 15cm wide POP at minimum
- Length – Handbreadth distal to elbow crease to just proximal to MCP joints
- Soft cotton roll applied with minimum 2 layer coverage, 50% overlap and no creases
- Dip plaster in room temp water until bubbles cease then hold up and concertina back into hand
- Apply plaster and smooth out any creases
- Crepe bandage applied firmly (stretches with time)
- Wrist 30 degrees dorsiflexed
- Broad-arm cotton sling provided
Long leg cast
Indications
- Peri-knee
- Tibial shaft
- Proximal fibula
Steps:
- Position patient supine if possible
- Prepare slab of 12 layers of 15cm wide POP at minimum + 6 layers of 10cm wide POP for stirrups x 2
- Length – Middle of posterior thigh to base of toes
- Cut slits at ankle bilaterally to allow overlap
- Soft cotton roll applied with minimum 2 layer coverage, 50% overlap and no creases
- Dip plaster in room temp water until bubbles cease then hold up and concertina back into hand
- Apply plaster and smooth out any creases
- Apply stirrups and smooth out any creases
- Crepe bandage applied firmly (stretches with time)
- Ankle 90 degrees and knee 10 degrees flexed
Tip – Can apply a short-leg cast first, then extend the backslab to the mid-thigh once set
Short-leg cast
Indications
- All other ankle/foot fractures as above
Steps:
- Position patient supine if possible
- Prepare slab of 12 layers of 15cm wide POP at minimum + 6 layers of 10cm wide POP for stirrups x 2
- Length – Handsbreadth distal to popliteal crease to base of toes
- Cut slits at ankle bilaterally to allow overlap
- Soft cotton roll applied with minimum 2 layer coverage, 50% overlap and no creases
- Dip plaster in room temp water until bubbles cease then hold up and concertina back into hand
- Apply plaster and smooth out any creases
- Apply stirrups and smooth out any creases
- Crepe bandage applied firmly (stretches with time)
- Ankle 90 degrees
Last Updated on July 14, 2021 by Andrew Crofton
Andrew Crofton
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