Emergency Department · Clinical Reference

Fracture & Dislocation Management — a quick reference

Initial ED treatment and onward disposition for common fractures, dislocations and limb soft-tissue injuries, grouped by anatomical area and colour-coded by destination.

Please read before using

These are general management plans followed in many hospitals and are intended mainly for reference and revision. Local pathways vary from trust to trust, so everyone should consult their own hospital’s local policy before acting on any of them. Always correlate radiology with clinical findings, and obtain a post-procedure check X-ray plus neurovascular assessment after every reduction, backslab or reduced dislocation.

Disposition options

Discharge · ED Review Clinic · Virtual Fracture Clinic · Fracture Clinic · Soft Tissue Clinic · Orthopaedic SHO on-call.

Always check after reduction

Post-reduction / post-backslab check X-ray plus neurovascular integrity (NVI) assessment for every reduction, backslab or reduced dislocation.

Urgent MUA in ED

Distal radial fractures may need urgent MUA in ED when there is immediate or impending neurovascular compromise (e.g. off-ended in adults) — using a haematoma or Bier’s block.

Where injuries are sent — colour key

Discharge from EDED Review ClinicVirtual Fracture ClinicFracture ClinicSoft Tissue ClinicRefer to OrthopaedicsRefer to MedicsPhysiotherapy / GP

Each card's coloured edge marks its highest-acuity destination.

Clavicle & Shoulder8 entries

Fracture clavicle (adults)

Virtual Fracture Clinic

Initial treatment Polysling

Fracture clavicle (children)

Discharge from ED · advice leaflet

Initial treatment Polysling

Acromio-clavicular joint injury — Grade 3 or above

Virtual Fracture Clinic

Initial treatment Polysling

Fracture proximal humerus

Fracture Clinic

Initial treatment

Collar and cuff

Lancaster sling if greater tuberosity #

Fracture greater tuberosity of humerus

Fracture Clinic

Initial treatment Polysling

Fracture shaft of humerus

Undisplaced: Fracture Clinic

Displaced: Refer to Orthopaedics

Initial treatment

Undisplaced: Humeral brace

Displaced: Humeral brace

Dislocated shoulder

Soft Tissue Clinic

Initial treatment Polysling after reduction

Fracture-dislocation shoulder

Refer to Orthopaedics

Initial treatment Polysling — reduction in ED / theatre

Elbow & Forearm10 entries

Dislocated elbow

Fracture Clinic

Initial treatment Reduce · backslab / polysling

Supracondylar fracture humerus (children) — undisplaced

Virtual Fracture Clinic

Initial treatment Above-elbow backslab · post-backslab AP & lateral X-ray

Supracondylar fracture humerus (children) — displaced

Refer to Orthopaedics

Initial treatment Above-elbow backslab in flexion as pain allows · post-backslab AP & lateral X-ray

Fracture radial head — undisplaced

Discharge from ED · advice leaflet

Initial treatment Collar and cuff

Fracture radial head / neck — displaced, marginal or comminuted

Fracture Clinic

Initial treatment Polysling · backslab if very painful

Fracture olecranon

Undisplaced: Virtual Fracture Clinic

Displaced: Refer to Orthopaedics

Initial treatment Backslab / polysling

Elbow dislocation

Refer to Orthopaedics

Initial treatment Post successful reduction: above-elbow backslab & check XR

Biceps distal tendon rupture

Refer to Orthopaedics

Initial treatment Polysling

Displaced forearm fractures · Monteggia · Galeazzi fracture-dislocation

Refer to Orthopaedics

Initial treatment Above-elbow POP backslab

Isolated ulna shaft fracture

Virtual Fracture Clinic

Initial treatment Above-elbow POP slab

Wrist & Distal Radius15 entries

DRUJ dislocation — XR hard to interpret — correlate clinically

Refer to Orthopaedics

Initial treatment Reduction & above-elbow backslab. Dorsal dislocation: immobilise in supination; volar dislocation: immobilise in pronation. Confirm reduction with true AP & lateral XR.

Confirmed scaphoid fracture

Fracture Clinic

Initial treatment Scaphoid POP

Query scaphoid fracture

ED Review Clinic · ED Review / Soft Tissue Clinic

Initial treatment Splint with thumb extension. Check XR at 10–14 days; if still clinically suspected after check XR → MRI protocol.

Carpal bone fracture

Undisplaced / minimal: Virtual Fracture Clinic

Displaced / dislocation: Refer to Orthopaedics

Initial treatment

Undisplaced / minimal: Futuro splint

Children — undisplaced / minimally displaced greenstick

Virtual Fracture Clinic

Initial treatment Backslab

Children — torus / buckle fracture

Discharge from ED · advice leaflet

Initial treatment Futuro splint

Children (<13 yrs) — displaced, requiring manipulation

Refer to Orthopaedics

Initial treatment Backslab

Salter-Harris fractures of distal radius / ulna

ED Review Clinic · discuss with ED Reg / Consultant / Ortho SHO if displaced

Initial treatment Backslab

Extra-articular adult — undisplaced / minimally displaced (<10%) or low functional demand — e.g. dementia, paralysed limb (stroke)

Virtual Fracture Clinic

Fracture Clinic · if a backslab is applied

Initial treatment Futuro splint with thumb extension

Intra-articular — undisplaced / minimally displaced (<10%) & non-angulated

Fracture Clinic

Initial treatment MUA & backslab

Colles fracture (extra-articular)

Fracture Clinic · if post-reduction XR satisfactory

Refer to Orthopaedics · if XR unsatisfactory, or median nerve symptoms

Initial treatment Haematoma / Bier's block, Penthrox — MUA & backslab

Colles fracture (intra-articular)

Refer to Orthopaedics

Initial treatment Haematoma / Bier's block, Penthrox — MUA & backslab

Smith's fracture

Refer to Orthopaedics

Initial treatment Backslab

Volar Barton's fracture

Refer to Orthopaedics

Initial treatment Above-elbow volar backslab with wrist extension

High-energy · open · neurological deficit · off-ended · grossly unstable distal radius & ulna

Refer to Orthopaedics

Initial treatment Backslab

Hand, Thumb & Fingers17 entries

CMC joint dislocation (4th & 5th CMC base)

Refer to Orthopaedics

Initial treatment Reduction & below-elbow backslab · confirm congruent reduction with true AP & lateral XR

Bennett's fracture — undisplaced — intra-articular base of thumb MC

Fracture Clinic

Initial treatment Bennett's POP

Bennett's fracture — displaced — intra-articular base of thumb

Refer to Orthopaedics

Initial treatment Bennett's POP

Fracture neck / shaft thumb metacarpal

Undisplaced: Virtual Fracture Clinic

Displaced: Fracture Clinic

Initial treatment

Undisplaced: Splint with thumb extension

Displaced: Reduction & backslab

Fracture little (5th) finger MC neck — undisplaced / minimal — no rotational or scissoring deformity

Discharge from ED · advice leaflet

Initial treatment Buddy strap

Fracture little (5th) finger MC neck — displaced — ≥40% displaced / ≥40° angulated / rotational deformity

Refer to Orthopaedics

Initial treatment Buddy strap with volar slab or Zimmer splint

Fracture 2nd–4th MC neck — undisplaced — no rotational or scissoring deformity

Virtual Fracture Clinic

Initial treatment Buddy strap

Fracture 2nd–4th MC neck — displaced

Refer to Orthopaedics

Initial treatment Buddy strap with volar slab or Zimmer splint

Fracture MC shaft / base — undisplaced — 4th & 5th MC base # need AP & lateral to assess CMC dislocation

Undisplaced: Virtual Fracture Clinic

Multiple MC #s: Fracture Clinic

Initial treatment

Undisplaced / minimal: Buddy strap & futuro splint

Multiple MC #s: consider buddy strap with volar slab

Fracture MC shaft — displaced

≤50% & multiple: Fracture Clinic

≥50% / rotational: Refer to Orthopaedics

Initial treatment

≤50% displaced / ≤50° angulated, no rotation: Reduction & buddy strap with volar slab

Multiple MC shaft / base: Volar slab

≥50% displaced / ≥50° angulated / rotational: Buddy strap with volar slab

Proximal / middle phalangeal fracture — undisplaced

Virtual Fracture Clinic

Initial treatment Buddy strap

Proximal / middle phalangeal fracture — displaced or rotated

Refer to Orthopaedics

Initial treatment Zimmer splint

Dislocated IP joints

Fracture Clinic

Initial treatment Reduce, buddy strap · true AP & lateral XR post-reduction

Crush fracture terminal phalanx

Closed: Virtual Fracture Clinic

Open: ED Review Clinic

Initial treatment

Closed: consider trephining

Open: wound washout +/- nail-bed repair in ED · non-adherent dressing · antibiotics if contaminated

Mallet finger (soft tissue)

Discharge from ED · advice leaflet

Initial treatment Mallet splint 6 weeks

Mallet finger (bony)

Virtual Fracture Clinic

Initial treatment Mallet splint

Tuft fracture terminal phalanx

Virtual Fracture Clinic

Initial treatment Consider mallet splint

Pelvis, Hip & Femur5 entries

Fracture pelvis

Refer to Orthopaedics

Initial treatment Treat hypovolaemia if required · major disruption = pelvic splint

Fracture pubic ramus

Discharge from ED · residents of care facilities discharge

Unable to mobilise: Refer to Medics

Initial treatment Analgesia & mobilise

Hip pain — unable to mobilise but negative X-ray

Refer to Medics · if no fracture & continuing symptoms; MRI / CT by Medics if unable to mobilise

Initial treatment Analgesia · exclude posterior tenderness / SIJ injury

Fracture neck of femur

Refer to Orthopaedics · use NOF fracture pathway

Initial treatment Analgesia, IV access & fluids, ECG · exclude compounding problems (e.g. pneumonia)

Fracture femur shaft

Refer to Orthopaedics

Initial treatment Treat hypovolaemia, X-match · nerve block, IV analgesia · Thomas splint & re-XR

Knee8 entries

Acute paediatric osteochondral fracture

Refer to Orthopaedics

Initial treatment Cricket pad splint

Hoffa's fracture

Refer to Orthopaedics

Initial treatment Cricket pad splint

Dislocated patella

Soft Tissue Clinic · Soft Tissue Knee Clinic

Initial treatment Reduce & cricket pad splint · check XR post-reduction

Fracture patella — NB bipartite patella

Undisplaced: Virtual Fracture Clinic

Displaced: Refer to Orthopaedics

Initial treatment Cricket pad splint

Quadriceps / patella tendon rupture

Refer to Orthopaedics

Initial treatment Cricket pad splint · arrange urgent USS if daytime presentation

Intercondylar tibial avulsion fracture

Refer to Orthopaedics

Initial treatment Cricket pad splint

Fracture tibial condyle / plateau — undisplaced

Virtual Fracture Clinic

Initial treatment Cricket pad splint

Fracture tibial condyle / plateau — displaced

Refer to Orthopaedics

Initial treatment Splint

Tibia & Fibula3 entries

Fracture tibial shaft — closed, undisplaced

Refer to Orthopaedics

Initial treatment Above-knee backslab

Fracture tibial shaft — displaced

Refer to Orthopaedics

Initial treatment Above-knee backslab

Fibula head / neck fracture

Fracture Clinic

Initial treatment Walker boot · check for medial ankle tenderness

Ankle10 entries

Pilon fracture — intra-articular distal tibia

Refer to Orthopaedics

Initial treatment Above-knee backslab

Displaced / unstable ankle fractures

Refer to Orthopaedics

Initial treatment Reduce / backslab and XR

Isolated tip of fibula OR tip of medial malleolus avulsion

Physiotherapy / GP

Initial treatment Treat as ankle sprain: RICE, +/- fixed walker boot, mobilise with crutches

Isolated Weber A distal fibula fracture

Virtual Fracture Clinic

Initial treatment Stable. Treat as ankle sprain: RICE, fixed walker boot, mobilise with crutches

Isolated undisplaced Weber B distal fibula fracture — no medial tenderness / bruising / talar shift

Fracture Clinic · weight-bearing

Initial treatment Stable. Treat as ankle sprain: RICE, fixed walker boot, mobilise with crutches

Isolated displaced Weber B distal fibula fracture — with medial tenderness / bruising / talar shift

Refer to Orthopaedics

Initial treatment Backslab

Isolated Weber C distal fibula fracture

Refer to Orthopaedics

Initial treatment Backslab

Bimalleolar / trimalleolar fracture

Refer to Orthopaedics

Initial treatment Backslab

Fracture-dislocation ankle

Refer to Orthopaedics

Initial treatment Reduction & backslab

Tendo-achilles rupture — high risk for DVT

Fracture Clinic

Initial treatment Weight-bear in a boot with 2 heel wedges +/- USS / VTE prophylaxis

Foot10 entries

Talus fracture

Fracture Clinic

Initial treatment Backslab · NWB & elevate

Calcaneal fracture

Undisplaced: Virtual Fracture Clinic

Displaced: Refer to Orthopaedics

Initial treatment Padded crepe if pain / swelling +++ (NWB), or walker boot if swelling allows (NWB) · analgesia & crutches

Tarsal bone fracture — undisplaced / minimally displaced

Undisplaced: Virtual Fracture Clinic

Displaced / dislocation: Refer to Orthopaedics

Initial treatment Walker boot & NWB

Tarsal fracture without disruption of tarsal alignment

Undisplaced: Virtual Fracture Clinic

Displaced: Refer to Orthopaedics

Initial treatment Fixed walker boot / backslab · analgesia & crutches

Intra-articular basal MT fracture / ? Lisfranc injury

Fracture Clinic

Initial treatment Backslab

Isolated metatarsal fracture

Undisplaced: Virtual Fracture Clinic

Displaced: Fracture Clinic

Initial treatment Fixed walker boot · weight-bear as tolerated

Multiple metatarsal fractures / crushed foot

Refer to Orthopaedics

Initial treatment Padded crepe · analgesia & crutches

Base of 5th MT fracture

Discharge from ED · advice leaflet

Initial treatment Fixed walker boot · analgesia & crutches

Jones fracture — 1.5 cm distal to tuberosity of 5th MT

Virtual Fracture Clinic

Initial treatment Fixed walker boot · analgesia & crutches

Base of 5th MT fracture (avulsion)

Discharge from ED · advice leaflet

Initial treatment Fixed walker boot · analgesia & crutches

Toes2 entries

Great toe fracture

Virtual Fracture Clinic

Initial treatment Toe spica (tape) · heel weight-bearing shoe

Undisplaced / non-angulated toe (phalangeal) fractures

Virtual Fracture Clinic

Initial treatment Buddy strap · heel weight-bearing shoe

Salter-Harris (Physeal) Injuries5 entries

Salter-Harris Type I

Undisplaced: Virtual Fracture Clinic · splint → VFC, or backslab → Fracture Clinic

Displaced: Refer to Orthopaedics

Initial treatment

Undisplaced: Casting or splinting

Salter-Harris Type II

Undisplaced: Virtual Fracture Clinic · splint → VFC, or backslab → Fracture Clinic

Displaced: Refer to Orthopaedics

Initial treatment

Undisplaced: Casting or splinting

Salter-Harris Type III

Refer to Orthopaedics

Initial treatment Backslab

Salter-Harris Type IV

Refer to Orthopaedics

Initial treatment Backslab

Salter-Harris Type V

Refer to Orthopaedics

Initial treatment Backslab

Referral Pathways

Soft Tissue Injury Clinic (knee & shoulder)

Refer suspected significant knee & shoulder injuries through soft-tissue clinic. AP and lateral X-rays must be taken before referral; discuss with a senior clinician first.

Refer if

Acute injury with haemarthrosis and no fracture on X-ray
Acute swelling within 2 hours, or a pop/snap heard or felt
Obvious effusion / haemarthrosis or ligament laxity
Locked knee (physical block to extension)
Cuff-strength weakness · first-time dislocation
ACL / significant ligamentous or meniscal injury
Patellar dislocation (after reduction & XR confirmation in ED)
Acute osteochondral injury (loose body)

Not for

Spontaneous acute inflammatory knee problems
Flare-ups of chronic conditions (e.g. osteoarthritis)
Minor soft-tissue injuries

MSK / ED Review Clinic

A review clinic (often a couple of mornings a week) for soft-tissue / MSK injuries needing review or safety-netting that don’t meet the soft-tissue pathway.

Include

Adult & paediatric soft-tissue / MSK injuries
Suspected scaphoid injuries — check X-ray 10–14 days post-injury
Spinal pain / condition; stable spinal fractures
Sports injuries; any injury with no confirmed fracture

Exclude

Facial & ENT injuries
Peripheral fractures (use the VFC / fracture-management route)
Tendo-achilles, digit, patella / quadriceps tendon, distal biceps ruptures → Ortho on-call
Burns & wounds → dressing clinic
Shoulder & knee soft-tissue injuries → soft-tissue clinic

Typical exclusions to Virtual Fracture Clinic

Book a face-to-face appointment instead

Homeless patients · those in custody
Non-English-speaking patients
Patients with hearing difficulties
Patients with dementia
Any safeguarding concern (at presentation or noted in records)
Any injury immobilised in a backslab (needs face-to-face fracture clinic, including alleged-assault cases)
Whenever a telephone consultation would be difficult or inappropriate

Reference summary for education and revision only. General plans practised in many hospitals — confirm against your local guidelines, which take precedence. Not a substitute for senior clinical judgement.