A&E Acute Orthopaedic Guidelines · Virtual Fracture Clinic

Virtual Fracture Clinic (VFC)

Virtual Hand Fracture Clinic (VHFC)

Latest A&E guidelines for treatment of common orthopaedic injuries (Updated November 2019)

If you have concerns about following these guidelines please consult your A&E senior or the Orthopaedic Registrar on-call.

Please refer to the correct team.

For the Virtual Fracture Clinic please use the online referral form. To contact this team please email uhsussex.fracturecare@nhs.net or call 63428.
For hand and wrist injuries please refer to The Virtual Hand Fracture Clinic by clicking here. To contact this team please email uhsussex.handtherapyservice@nhs.net or call extension 4116.

We DO NOT accept referrals for:

Spine injuries including soft tissue/whiplash injuries
Children under the age of 16
Open fractures - these should always be referred to the Orthopaedic on-call team
Dislocated total hip replacements.
The VFC does not accept referrals for wounds. Please refer to Orthopaedic on call team

Guidance:

Minor soft tissue injuries do not routinely require a Virtual Fracture Clinic referral. These injuries generally resolve with time. If symptoms persist over 6 weeks, the patients GP can refer to the MSK Partnership. If you think referral to the VFC is required, please be specific and detailed in your reason for referral.
We welcome feedback/comments. Please direct them to the appropriate team.

Please include an email address and phone number on the referral. This improves our ability to contact patients.

There has been an increase in unnecessary toe fracture referrals. Generally these need reassurance that it will heal with time (approx. 6-12 weeks), analgesia, comfortable footwear and no onward referral. Please refer to the guidelines below.

Click below to jump to body region:

Spine
Hand and Wrist
Shoulder and Elbow
Lower Limb

Spine

Fracture	Subcatagory	A&E Management
C-spine fracture		Refer spinal on-call
L-spine fracture	Stable wedge fracture	Refer spinal on-call
	All others	Refer spinal on-call
T-spine fracture		Refer spinal on-call
Spine sprains/whiplash injuries		Please do not refer to virtual fracture clinic, GP refer into MSK service if necessary
Non-traumatic neck/back pain		Exclude infection Do not refer to virtual fracture clinic GP review or refer to spine service as outpatien

Hand and Wrist

NB: If Surgery is indicated please ensure a Covid-19 swab is taken. This will avoid bringing the patient back.

Fracture

Subcategory

A&E Management

High pressure injection injury

Urgent referral to Ortho on-call

Open fracture/joint

Possible tendon injury

Possible nerve injury

Crush injury

Concerning open wound

Concerning infection

Irreducible dislocation

Refer Ortho on-call

Distal radial fractures – check median nerve

Reduce

Back slab

Please refer to video guidance:

Video: How to Apply a Dorsal Backslab for Distal Radius Fractures

Video: How to Reduce and Hold a Distal Radius Fracture Using Finger Traps

On-line referral to virtual hand fracture clinic

Injured wrist - no obvious fracture/possible scaphoid

Backslab

On-line referral to virtual hand fracture clinic

Scaphoid fractures

Backslab

On-line referral to virtual hand fracture clinic

Other carpal fracture/injury – check median nerve

Reduce if needed

Back slab

On-line referral to virtual hand fracture clinic

Metacarpal fractures

Neck

Bedford Splint

On-line referral to virtual hand fracture clinic

Shaft

Futura

On-line referral to virtual hand fracture clinic

Base

Reduce if needed

Back slab

On-line referral to virtual hand fracture clinic

Phalangeal fractures

Reduce if needed

Bedford Splint

On-line referral to virtual hand fracture clinic

Mallet injury

Mallet splint

On-line referral to virtual hand fracture clinic

Thumb fractures

Distal phalanx

Reduce if needed

Mallet splint

On-line referral to virtual hand fracture clinic

Other fracture or ligament injury

Reduce if needed

Thumb cast

On-line referral to virtual hand fracture clinic

Shoulder and Elbow

Types of slings:

Fracture	Subcategory	A&E Management
Sternoclavicular joint dislocation	Anterior or superior	Polysling, Analgesia On-line referral to virtual fracture clinic
	Posterior	Refer to Ortho on-call team
Clavicle fractures	Open fracture, threat to skin and/or neurovascular compromise	Refer to Ortho on-call team
	Closed injury, no threat to skin or neurovasular compromise	Polysling/double collar and cuff Analgesia On-line referral to virtual fracture clinic
Acromioclavicular joint injuries		Polysling/double collar and cuff Analgesia On-line referral to virtual fracture clinic
Soft tissue shoulder injuries	Including proximal biceps tendon injuries and suspected rotator cuff tears	Polysling or double loop collar & cuff Analgesia On-line referral to virtual fracture clinic
Anterior Shoulder dislocations		Reduce Polysling Analgesia On-line referral to virtual fracture clinic
Posterior shoulder dislocations	Traumatic or following epileptic seizure	Refer to Ortho on-call for advice before reduction. A proximal humeral fracture must be excluded.
	Previous multiple posterior dislocations (normally due to multidirectional instability)	Reduce Polysling Analgesia On-line referral to virtual fracture clinic
Acute Atraumatic Shoulder Pain (including Calcific Tendonitis)			Exclude infection (temp, FBC, CRP) and other red flags. Collar & Cuff (single or double loop) Analgesia Refer to GP
Proximal humeral fractures	Greater tuberosity and or surgical neck fracture		Collar & Cuff Analgesia On-line referral to virtual fracture clinic
Humeral shaft fractures	Open fracture, significantly displaced or radial nerve injury		Refer to Ortho on-call
	Closed fracture, reasonable alignment & radial nerve intact		Collar & Cuff Analgesia On-line referral to virtual fracture clinic
Distal Biceps tendon rupture			Refer to Ortho on-call
Distal humeral fracture			Refer to Ortho on-call
Olecranon fractures	Undisplaced		Above elbow backslab Collar and Cuff Analgesia On-line referral to virtual fracture clinic
	Displaced		Refer Ortho on-call
Radial head/neck fractures	Radiohumeral joint located & no associated fracture of ulna		Collar & cuff (single or double loop) Analgesia On-line referral to virtual fracture clinic
	Radiohumeral joint subluxed or dislocated and or associated fracture of ulna		Refer Ortho on-call
Dislocated elbow			Relocate under sedation Polysling - elbow in 90 degrees flexion Analgesia On-line referral to virtual fracture clinic
Radial & ulna midshaft fractures Any fractures within 5cm of wrist should be referred to VHFC.	Nightstick ulna (undisplaced)		Above elbow cast (90deg flexion, neutral rotation) Polysling Analgesia On-line referral to virtual fracture clinic
	All others		Refer Ortho on-call

Lower Limb

Fracture

Subcatagory

A&E Management

Pelvic fracture

APC, LC, VS

Treat hypovolaemia

Refer Ortho on-call

Low energy, elderly pubic rami fractures

Mobilise FWB, investigate cause of fall, discharge planning as per best practise tariff

Avulsion fractures

Analgesia

On-line referral to virtual fracture clinic

Acetabular fracture

Refer Ortho on-call

Neck of femur

Refer Ortho on-call

Dislocated Total hip replacement

First dislocation

Refer Ortho on-call

For reduction in theatre

Had previous dislocation

Reduce in ED if possible or refer Ortho on-call

Even if reduced and patient fit for discharge please give details to Ortho Reg on-call to make out-patient appointment with relevant consultant

Do not refer to VFC

Hip pain post fall, no fracture on plain x-ray

If able to fully weight bear

Discharge

On-line referral to virtual fracture clinic

Unable to FWB

Refer Ortho on-call

Femoral shaft fracture

Refer Ortho on-call

Distal femoral fracture

Refer Ortho on-call

Thigh injury/haematoma

Exclude compartment syndrome

On-line referral to virtual fracture clinic

Calf Muscle Tear

Weight bear as tolerated

Boot and wedges for comfort if required. Advised to wean off wedges as soon as able.

If significant injury, refer to VFC.

Soft tissue knee injuries

Mild soft tissue knee injury

Meniscal injury possibly suspected

Reassure likely to resolve with time

Mobilise FWB

See GP 6/52 if still symptomatic

Patella tendon rupture or quads tendon rupture

Refer Ortho on-call

Suspected meniscal or ligament injury, has full extension

Tubigrip or cricket pad splint

On-line referral to virtual fracture clinic

Suspected meniscal or ligament & block to full extension

Refer as locked knee to Ortho on-call

Atraumatic swollen knee

Apyrexial, normal CRP & WCC. No infection or other red flags.

On-line referral to virtual fracture clinic

Any of the above or recent knee surgery

Refer to Ortho on-call

Patella Fracture

Un-displaced

Cricket pad splint

Full weight bearing

Online referral to virtual fracture clinic

Displaced or vulnerable to displacement

Refer to Ortho on-call

Patella dislocation

Primary

Reduce

AP, Lateral & Skyline x-ray

Cricket pad splint

Full WB, crutches if needed

On-line referral to virtual fracture clinic

Recurrent

Reduce

AP, Lateral & Skyline x-ray

Cricket pad splint if needed

Full WB

On-line referral to virtual fracture clinic

Tibial plateau fractures

Refer Ortho on-call

Above knee backslab

Tibia

Proximal

Refer Ortho on-call

Above knee backslab

Shaft: undisplaced

Above knee backslab

Refer Ortho on-call

Shaft: displaced

Reduce & above knee backslab

Refer Ortho on-call

Distal/Pilon fractures

Refer Ortho on-call

Proximal and Mid-shaft fibula fractures

Proximal fibula fracture

Screen for ankle pain/possible maisonneuve injury. If positive, refer to Ortho on-call.

If negative:
Crutches

Weight bear as tolerated

Online referral to virtual fracture clinic

Mid-shaft fibula fracture

Screen for ankle pain/possible maisonneuve injury. If positive, refer to Ortho on-call.

If negative:

Boot for comfort (optional)

Crutches

Weight bear as tolerated

Online referral to virtual fracture clinic

Soft tissue ankle injury/sprain

Compression bandage

Black boot if severe

Weight bear as tolerated

Most soft tissue ankle injuries do not need referral to VFC. Refer only if severe injury or clinical concerns.

Ankle fractures

Weber A fibula fracture

Black boot

Weight bear as tolerated

On-line referral to virtual fracture clinic

Weber B fibula fracture

No talar shift

Black boot

Weight bear as tolerated

On-line referral to virtual fracture

Weber B fibula fracture

Talar shift

Reduce

Backslab

Refer Ortho on-call

Weber C

No talar shift

Black boot

Refer Ortho on-call

Weber C

Talar shift

Reduce

Backslab

Refer Ortho on-call

Bimalleolar/trimalleolar

Reduce if needed

Backslab

Refer Ortho on-call

Isolated medial malleolus

Undisplaced

X-Ray of full length tibia/fibula must be done to rule out proximal fibula fracture. If fracture identified, refer to ortho on call.

If no proximal fibula fracture:

Black boot

Weight bear as tolerated.

On-line referral to virtual fracture clinic

Isolated medial malleolus

Displaced

Refer Ortho on-call

Hindfoot injuries

Talus or Calcaneal fractures +/- dislocation

Backslab

Refer Ortho on-call

Small avulsion fractures of talus / calcaneum

(EXCEPT superior talus - see below)

Black boot

Weight bear as tolerated

On-line referral to virtual fracture clinic

Avulsion fracture superior talus

CT request - to be reviewed in VFC

Touch weight bearing in black boot

No ankle exercises

Prophylactic enoxaparin for 4 weeks

Refer VFC

Achilles tendon rupture

If diagnosis in doubt consult A&E senior or Ortho Registar on-call

Rebound boot with 5 wedges or, if unavailable, black boot with 5 wedges.

Urgent outpatient USS to confirm diagnosis and size of gap. (A&E to send form please, Confirm on referral form that USS organised)

Weight bear as tolerated.

Prophylactic Enoxaparin prescribed for 42 days

Referral to VFC

Midfoot injuries

Avulsion fractures of tarsal bones

Black boot

Full weight bear

On-line referral to virtual fracture clinic

Tarsal fractures - Undisplaced

Request urgent outpatient CT for VFC review

Black boot

NWB

On-line referral to virtual fracture clinic

Tarsal fractures - Displaced

Backslab

Refer Ortho on-call

Lis-franc fracture / dislocation

Including suspected on basis of mechanism / swelling / planter bruising

Backslab

Refer Ortho on-call

Forefoot injuries

1st metatarsal fracture

Black boot

Heel weight bear

On-line referral to virtual fracture clinic

2nd-4th metatarsal - single fracture

Black boot

Weight bear as tolerated

On-line referral to virtual fracture clinic

2nd-4th metatarsal - multiple fractures

Black boot

Weight bear as tolerated

On-line referral to virtual fracture clinic

Hallux phalanx fracture - intra-articular

Black boot/loose shoe

Weight bear as tolerated

On-line referral to virtual fracture clinic and give patient care plan and advise only to be contacted if a change in management is required

If there is a wound to be followed up by GP Practice nurse

Hallux Phalanx fracture - undisplaced

Black boot three weeks

Weight bear as tolerated

Discharge

Hallux Phalanx fracture - displaced

Reduce
Black boot three weeks

Weight bear as tolerated

Online referral to virtual fracture clinic and give patient care plan and advise only to be contacted if a change in management is required

If there is a wound to be followed up by GP Practice nurse

Lesser phalanx fracture

Neighbour strap two weeks

Weight bear as tolerated

Discharge

Toe dislocations

Reduce

Neighbour strap two weeks

Weight bear as tolerated

Discharge unless reduction is unstable. If unstable, online referral to virtual fracture clinic.

Base of 5th metatarsal fracture

Black boot three weeks

Weight bear as tolerated

Online referral to virtual fracture clinic and give patient care plan and advise only to be contacted if a change in management is required

Midshaft of 5th metatarsal fracture

Black boot

Weight bear as tolerated

On-line referral to virtual fracture clinic