A&E Acute Orthopaedic Guidelines · Virtual Fracture Clinic

Latest A&E guidelines for treatment of common orthopaedic injuries (Updated March 2024)

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 as below

For Adult Virtual Fracture Clinic:

Please use the online referral form

We are an acute service and only manage injuries within the first 6 weeks

All patients referred to the Adult Virtual Fracture Clinic require x-rays except calf muscle tears and suspected Achilles tendon injuries

Please put as much information about the patient on the referral as possible

This team can be contacted by email on uhsussex.fracturecare@nhs.net or via ext 63428

Minor soft tissue injuries do not routinely require a VFC referral and usually resolve with time. Patients can self-refer to MSK Partnership if their symptoms do not resolve within 6 weeks.

Please note- we DO NOT accept referrals for:

Spinal injuries including soft tissue/whiplash injuries
Children under 16 – refer to Paediatric Virtual Fracture Clinic via Panda
Open fractures - refer to orthopaedic registrar on-call
Dislocated total hip replacements- refer to orthopaedic registrar on-call
Post-operative conditions
Wounds or foreign bodies – refer to orthopaedic registrar on-call

If the referral does not fit our criteria it may be declined and returned to you via email

For Adult Virtual Hand Fracture Clinic:

For hand and wrist injuries please refer to The Adult Virtual Hand Fracture Clinic by clicking here
We are an acute service and only manage injuries within the first 4 weeks
To contact this team please email uhsussex.handtherapyservice@nhs.net or call extension 64116.
Minor soft tissue injuries do not routinely require a VFC referral and usually resolve with time. Patients can self-refer to MSK Partnership if their symptoms do not resolve within 6 weeks. If you think that a referral to the VHFC is required, please be specific and detailed in your reason for referral.
Please note- we DO accept referrals for:
- Hand and wrist open fractures
- Hand and wrist wounds or foreign bodies

For the Paediatric Virtual Fracture Clinic:

Please refer any patients under 16 to the Paediatric Virtual Fracture Clinic.

This can be done by completing the referral form on Panda

This team can be contacted on uhsussex.paediatricvirtualfractureclinic@nhs.net

Click below to jump to body region:

Spine

Hand and Wrist

Shoulder and Elbow

Lower Limb

Spine

Fracture	Subcategory	A&E Management
C-spine fracture		Refer to spinal on-call during the day, neurosurgery during the night
L-spine fracture	Stable wedge fracture	Refer to spinal on-call during the day, neurosurgery during the night
	All others	Refer to spinal on-call during the day, neurosurgery during the night
T-spine fracture		Refer to spinal on-call during the day, neurosurgery during the night
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 outpatient

Hand and Wrist

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 neurovascular compromise	Polysling/double collar and cuff Analgesia On-line referral to virtual fracture clinic
Acromioclavicular joint injuries	Closed, neurovascular intact and skin not under threat	Polysling/double collar and cuff Analgesia On-line referral to virtual fracture clinic
	Any evidence of open injury, neurovascular compromise or threat to skin	Refer to ortho reg on call
Soft tissue shoulder injuries	Acute on chronic	Polysling or double loop collar & cuff Analgesia Contact GP or self-refer to MSK partnership if not settling with 6 weeks
	Acute Minor soft tissue injuries	Polysling or double loop collar & cuff Analgesia Contact GP or self-refer to MSK partnership if not settling with 6 weeks
	Suspected rotator cuff tears and long head of biceps tendon ruptures	Polysling or double loop collar & cuff Analgesia On-line referral to virtual fracture clinic
Anterior Shoulder Dislocations	Primary Dislocation	Reduce Polysling Analgesia On-line referral to virtual fracture clinic
	Recurrent Dislocation	Reduce Polysling Analgesia On-line referral to virtual fracture clinic
Shoulder fracture dislocation Post reduction	Non-displaced fracture	Polysling Analgesia On-line referral to virtual fracture clinic
	Displaced fracture	Refer to Ortho on-call
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	Minimally displaced greater tuberosity and or surgical neck fracture	Collar & Cuff Analgesia On-line referral to virtual fracture clinic
	Displaced fracture or more than 2 part fracture (providing neurovascularly intact)	Collar & cuff Online referral to VFC
	If any concerns re: neurovascular status	Ortho reg on call
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) or polysling 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
Fracture dislocation elbow Post reduction		Refer to ortho reg
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	Subcategory	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	Refer Ortho on-call
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 If ongoing issues to reattend ED or see GP
	Unable to FWB	Further imaging to exclude fracture If no fracture discharge
Femoral shaft fracture		Refer Ortho on-call
Distal femoral fracture		Refer Ortho on-call
Thigh injury/haematoma	Exclude compartment syndrome	Discharge
	Proximal hamstring tendon rupture	Refer Ortho on-call
Calf Muscle Tear	Ensure Achilles tendon injury is ruled out by Simmonds testing and palpation If any doubt about Achilles treat as suspected Achilles rupture	Weight bear as tolerated Boot +/- 3 wedges for comfort if required. Advised to wean off wedges as soon as able. If significant injury, refer to VFC. Complete VTE Risk Assessment
Acute soft tissue knee injuries (within last 6 weeks)	Mild soft tissue knee injury	Reassure likely to resolve with time Mobilise FWB and encourage ROM See GP 6/52 if still symptomatic
	Acute on chronic OA exacerbation	Discharge to GP Advise to self-refer to MSK Partnership if doesn’t settle
	Patella tendon rupture or quads tendon rupture	Refer Ortho on-call
	Suspected acute meniscal tear or ligament injury without true locking/block to extension	Crutches to aid mobility if required Cricket pad splint for comfort if required Complete VTE Risk Assessment if CPS given X-rays and online referral to virtual fracture clinic
	Suspected acute meniscal tear with true locking/block to extension	Refer to Ortho on-call as locked knee
Atraumatic painful/swollen knee	Apyrexial, normal CRP & WCC. No infection or other red flags.	Discharge back to GP
	Any of the above infectious signs/red flags or recent knee surgery	Refer to Ortho on-call
Patella Fracture	Un-displaced	Cricket pad splint Complete VTE Risk Assessment Full weight bearing Online referral to virtual fracture clinic
	Displaced or vulnerable to displacement	Refer to Ortho on-call Complete VTE Risk Assessment
Patella dislocation	Primary	Reduce AP, Lateral & Skyline x-ray Cricket pad splint Complete VTE Risk Assessment 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 Complete VTE Risk Assessment VFC will decline any referral for a tibial plateau fracture
Tibia	Proximal	Refer Ortho on-call Above knee backslab Complete VTE Risk Assessment
	Shaft: undisplaced	Refer Ortho on-call Above knee backslab Complete VTE Risk Assessment
	Shaft: displaced	Refer Ortho on-call Reduce & above knee backslab Complete VTE Risk Assessment
	Distal/Pilon fractures	Refer Ortho on-call Complete VTE Risk Assessment
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 Complete VTE Risk Assessment
	Mid-shaft fibula fracture	Screen for ankle pain/possible maisonneuve injury. If positive, refer to Ortho on-call. WB ankle views (if possible) If negative: Boot for comfort (optional)- if given complete VTE Risk Assessment Crutches Weight bear as tolerated Online referral to virtual fracture clinic
Soft tissue ankle injury/sprain		Compression bandage Black boot if severe- Complete VTE Risk Assessment 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 Complete VTE Risk Assessment On-line referral to virtual fracture clinic
	Weber B fibula fracture No talar shift	Black boot Weight bear as tolerated Complete VTE Risk Assessment On-line referral to virtual fracture
	Weber B fibula fracture Talar shift	If concern re: talar shift then complete weight bearing ankle XRs (mortise and lateral) or CT scan and discuss with ortho on call
	Weber C No talar shift	Black boot Complete VTE Risk Assessment Refer Ortho on-call
	Weber C Talar shift	Reduce Backslab Complete VTE Risk Assessment Refer Ortho on-call
	Bimalleolar/trimalleolar	Reduce if needed Backslab and CT scan Complete VTE Risk Assessment Refer Ortho on-call
Medial Malleolus fractures	Isolated medial malleolus Small Fragment- 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. Weight bearing ankle x-rays (if possible) If no proximal fibula fracture: Black boot Complete VTE Risk Assessment Weight bear as tolerated. On-line referral to virtual fracture clinic
	Isolated medial malleolus Large fragment - undisplaced	Refer Ortho on-call Complete VTE Risk Assessment
	Isolated medial malleolus Displaced	Refer Ortho on-call Complete VTE Risk Assessment
Hindfoot injuries	Talus or Calcaneal fractures +/- dislocation	CT Backslab Complete VTE Risk Assessment Refer Ortho on-call
	Small avulsion fractures of calcaneum	Black boot Complete VTE Risk Assessment Weight bear as tolerated On-line referral to virtual fracture clinic
	Avulsion fracture from talus	Black boot Complete VTE Risk Assessment On-line referral to virtual fracture clinic
	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 be requested Weight bear as tolerated. Prophylactic Enoxaparin prescribed for 42 days Please print this advice leaflet and give to patient Online referral to virtual fracture clinic
Midfoot injuries	Avulsion fractures of tarsal bones	Black boot Complete VTE Risk Assessment Full weight bear Online referral to virtual fracture clinic
	Tarsal fractures - Undisplaced (Navicular, cuboid, cuneiforms)	Black boot Complete VTE Risk Assessment NWB On-line referral to virtual fracture clinic
	Tarsal fractures - Displaced	Backslab Complete VTE Risk Assessment CT Refer Ortho on-call
	Lis-franc fracture / dislocation Including suspected on basis of mechanism / swelling / planter bruising	CT Backslab Complete VTE Risk Assessment Refer Ortho on-call
Metatarsal fractures	Base of metatarsal fractures- undisplaced	CT scan for VFC review Black boot Complete VTE Risk Assessment Weight bear as tolerated On-line referral to virtual fracture clinic
	Base of metatarsal fractures- displaced	CT Blackboot NWB Complete VTE Risk Assessment Refer Ortho on-call
	1st metatarsal fracture	Black boot Complete VTE Risk Assessment Heel weight bear On-line referral to virtual fracture clinic
	2nd-4th metatarsal - single fracture	Black boot Complete VTE Risk Assessment Weight bear as tolerated On-line referral to virtual fracture clinic
	2nd-4th metatarsal - multiple fractures	Black boot Complete VTE Risk Assessment Weight bear as tolerated On-line referral to virtual fracture clinic
	Midshaft of 5^th metatarsal fracture	Black boot Complete VTE Risk Assessment Weight bear as tolerated On-line referral to virtual fracture clinic
	Base of 5^th metatarsal fracture	Black boot three weeks Complete VTE Risk Assessment Weight bear as tolerated Give patient care plan and advise will only be contacted if a change in management is required Online referral to virtual fracture clinic and give patient care plan and advise will only be contacted if a change in management is required
Toe fractures	Hallux phalanx fracture - intra-articular	Black boot/loose shoe If boot given- Complete VTE Risk Assessment Weight bear as tolerated Online referral to virtual fracture clinic and give patient care plan and advise will only 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 Complete VTE Risk Assessment Weight bear as tolerated Discharge
	Hallux Phalanx fracture - displaced	Reduce Black boot Complete VTE Risk Assessment Weight bear as tolerated Online referral to virtual fracture clinic and give patient care plan and advise will only 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.