Author: Sarah Edwards, based on blog by Abhinav Singh / Editor: Charlotte Davies / Questions: Sarah Edwards / Codes: / Published: 31/07/2018, reviewed 29/07/2020

With the advent of urgent care centres, your exposure to orthopaedics won’t be what it used to be. However, if you follow some of the basic tips here, your orthopaedic surgeons and patients will be happy!

Bones have been healing for longer than orthopods have been around. There are two types of fixation- with absolute and relative stability which affects the mechanism of bone healing. The general rule is that all displaced fractures should be “reduced” (either open or closed) and then held in position through plaster of paris casts or plates/screws/intra and extramedullary fixation devices until healed.

First up is “should I x-ray”? If you’re not sure, have a chat with your senior. There are some decision tools to help you look at the ankle, knee and c-spine. Generally, we don’t x-ray toes, as the management doesn’t alter, and we x-ray the pelvis of every frail patient who falls. We haven’t covered interpretation of x-rays here as that’s comprehensively covered by Radiopedia and the elfh radiology programme.

For all fractures:

  • Provide appropriate analgesia.
  • Prior to referring always comment on neurovascular status, ensure that the joint above and below is examined and imaged.
  • Document when the patient last ate or drank.
  • Consult seniors in the emergency department and/or radiology reporting before speaking to orthopaedics to “review” an x-ray.

Not all fractures need to be admitted into the hospital as many of these patients will be managed via the fracture-clinic pathway. Operations can be arranged via the fracture clinic, but the majority of patients need conservative management.

Specific Fractures

We’ve not covered all the fractures you’ll see here, just a few of them. For more details, look at your Trust’s guidelines, or some of the RCEM Learning reference guides. If you’re concerned about upper limb fractures, we have a separate blog post here.

Colles Fracture: This is a stable fracture of the wrist, with a traditional dinner fork deformity on x-ray. It needs reducing, and the patient put in a colles (below elbow) backslab with fracture clinic follow up. We have a whole blog on how to manipulate here.
Smiths and Bartons fractures are managed similarly – speak to your ED senior for advice.

Proximal Humerus: Fractures in the elderly without associated joint dislocation and gross rotational deformity can be managed with collar & cuff and be seen in fracture-clinic. Midshaft humerus fractures require a U-slab and discussion with the ortho SHO. Some of these may be suitable for conservative management – some need an operation.

Clavicle: Surgical management depends on the fracture location (medial, midshaft, lateral), pre injury function, neurovascular injury and the state of the overlying skin. If there is any neurovascular injury and/or open fractures surgical fixation is needed. If neither is present, place the affected side into a polysling and refer for outpatient management.

Femur: You will see a lot of neck of femur fractures (NOFs), and most departments have a fractured neck of femur pathway. These patients require an ECG, chest xray, baseline bloods (including 2x group and save) and fascia iliaca block to be done in the emergency department, prior to referring to the T&O SHO.

Ankle: Extremely common. Fracture/dislocations are reduced swiftly in the emergency department – if the ankle looks wobbly, let your senior know ASAP! Ankle fractures need immobilisation – have a look at the Weber catagory to see if they need a boot, or a plaster of paris. Most trusts agree that tubigrip isn’t worth using.

Tarsal/Metatarsals: Undisplaced metatarsal head fractures are generally managed conservatively with protected weight-bearing. However, pay close attention to the clinical history. Lisfranc fractures can be easily missed, if not considered.

Scaphoid Fractures: Early diagnosis of a scaphoid fracture is crucial to avoid the potential complication of non-union, psuedoarthiritis and avascular necrosis. Scaphoid fractures are estimated as being the most common fracture of the carpal bones. Comprising of nearly 90% of carpal fractures. Missed scaphoid fractures also have a significant litigative cost to them, with average pay-outs around £20000 pounds.

It is important in any wrist injury to consider a scaphoid fracture and document that you have considered this. In medical school, students are often taught that tenderness in the anatomical snuff box (ASB) is the gold standard sign, which is specific and sensitive for a scaphoid fracture. However, it is important to consider the anatomy in the area of the ASB. The cutaneous branch of the radial nerve runs directly over the ASB, therefore discomfort may occur on firm palpation even in the absence of injury. There are a number of tests that a clinician can use in determining if there is a scaphoid injury.

These include:

  1. Palpation of the ASB
  2. Pressing the scaphoid tubercle (SC)
  3. Applying longitudinal force to the thumb through axial loading or telescoping the thumb (LC)

This video here shows how to examine for a suspected scaphoid fracture.

Management of suspected scaphoid fractures: It is important to have a high degree of suspicion of a scaphoid fracture if on examination the following tests; ASB, SC and LC are all positive (produce pain). The combination of positive findings of all three tests is highly suggestive of a scaphoid fracture (sensitivity 100%, specificity 74%). If no fracture is seen and there is a high index of suspicion of scaphoid injury. It is prudent to treat as a presumed scaphoid fracture and arrange appropriate immobilisation and follow-up as stated locally.

The Royal College of Emergency Medicine’s (RCEM) 2013 guideline produced the following flow chart which may be useful when considering the management of suspected scaphoid fractures.

Elbow injuries – especially those in children

It is crucial for elbow injuries, that the neurovascular status of the limb is documented clearly. As an estimated 10% of elbow injuries as a whole can have some neurovascular compromise. The BOAST (British Orthopaedic Association Standards for Trauma) guideline 2015, states specifically for supracondylar fractures that each individual nerves need to be documented. The four required nerves for documentation are the radial, ulna, median and anterior interosseous nerves.

However, it would probably be good practice to document these nerves in any upper limb injury. We cover more on this below in the “children” section.

Other Orthopaedic Diagnoses

Open fractures: Administer prophylactic antibiotics, consider tetanus. Mini-washouts outside the operating theatre are not indicated, as per BOAST guideline.

Septic arthritis: Consider this diagnosis in any patient with an acute joint swelling in association with being clinically unwell and inability to weightbear. Joint aspirate may be indicated but a negative tap does not rule out a septic joint. Clinical history and correlation is paramount.

Necrotising fasciitis: These patients are generally extremely unwell. LRINEC criteria can be used to score these patients however, clinical judgement is most important. Escalate these patients urgently to your seniors with prompt involvement of intensive care is mandated but immediate surgical consultant for potential operative debridement is key.

Cauda Equina: CES is a medical emergency. It can be a challenging diagnosis especially in those patients who already have chronic lower back pain. Missed CES can have a massively impact patient ability to walk, have sex and lead a normal life. It is one of the highest ligation costs to the NHS, with an average pay out for a missed diagnosis between £250000 -£350000

Red flags specific for cauda equina are:

  • Bilateral sciatica
  • Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.
  • Difficulty initiating micturition or impaired sensation of urinary flow. If untreated, this may lead to irreversible urinary retention with overflow urinary incontinence
  • Loss of sensation of rectal fullness. If untreated, this may lead to irreversible faecal incontinence
  • Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia).
  • Laxity of the anal sphincter.

Further information can be found about other black pain red flags here and it is covered on our back pain induction blog.

Here are two great infographics from Dr Linda Dykes, summarising CES and the new guidelines.


Around 25% of the patients we see in the emergency department are children. One of the most common presentations is an injury, often related to playing. We’ve got many more blogs on paediatric presentations, including our paediatric iBook, and DFTB have some excellent modules. Here are a few important considerations.

Non-accidental injury

With children it is always important to consider “was the injury an NAI”. Its good practice to strip any child under five off completely, and complete a body map.

Further information can be found here at our blog.

Types of injury: The age of the child will often determine how bones get injured i.e. younger children will often bend rather than break their bones. Therefore, you will see injuries that are only child specific i.e. buckle fractures, supracondylar fractures and fractures involving ossification centres (Salter Harris Fractures).

Image from medcomic

 Buckle Fractures: This is one of the most common paediatric fractures that present to the emergency department in the UK. It is estimate around 500000 presentations of buckle fracture attend EDs in the UK every year. This infographic from EM3 summarises buckle fractures.

Supracondylar fractures Upper limb fractures in children account for over 80% of all paediatric fractures presenting to the emergency department. Acute elbow trauma accounts for an estimated 2%–3% of all visits to the emergency department, with elbow injuries making up an estimated 25% of all paediatric sport-related injuries. The incidence of supracondylar fractures is estimated at 177.3 per 100 000.

It is crucial for elbow injuries, that the neurovascular status of the limb is documented clearly. As an estimated 10% of elbow injuries as a whole can have some neurovascular compromise. The BOAST (British Orthopaedic Association Standards for Trauma) guideline 2015, states specifically for supracondylar fractures that each individual nerves need to be documented. The four required nerves for documentation are the radial, ulna, median and anterior interosseous nerves.

A simple way to assess the neurological status of the upper limb in both children and adults can be the Rock, Paper, Scissors, OK method. Matched like the children’s game, this can help to examine the neurology and document the specific nerves. Rock tests the median nerve, paper tests the radial nerve, scissors tests the ulna nerve and the ok sign tests the anterior interosseous nerve.

Here is an infographic helping you remember these tests.

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References and Further Reading


  1. Atrey A, Nicolaou N, Katchburian M, Norman-Taylor F. A review of reported litigation against English health trusts for the treatment of children in orthopaedics: Present trends and suggestions to reduce mistakes. J Child Orthop. 2010;4(5):471-476. doi:10.1007/s11832-010-0276-4
  2. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: A meta-analysis. J Pediatr Orthop. 2010;30(3):253-263. doi:10.1097/BPO.0b013e3181d213a6
  3. Colton C, Monsell F. Supracondylar humeral fractures in children – have we stopped thinking? J Trauma Orthop. 2016;04(02):48-52.
  4. Clark EM. The epidemiology of fractures in otherwise healthy children. Curr Osteoporos Rep. 2014;12(3):272-278. doi:10.1007/s11914-014-0227-y
  5. Davidson AW. Rock-paper-scissors. Injury. 2003;34(1):61-63. doi:10.1016/s0020-1383(02)00102-x
  6. Marsh AG, Robertson JS, Godman A, Boyle J, Huntley JS. Introduction of a simple guideline to improve neurological assessment in paediatric patients presenting with upper limb fractures. Emerg Med J. 2016;33(4):273-277. doi:10.1136/emermed-2014-204414
  7. Talbot CL, Ring J, Holt EM. Litigation relating to conditions affecting the shoulder and elbow: An analysis of claims against the National Health Service. Bone Jt J. 2014;96 B(5):574-579. doi:10.1302/0301-620X.96B5.33257
  8. Dobyns JH BR, Bryan RS, et al. Fractures of the hand and wrist. In: Flynn JE, editor. Hand Surgery. Edinburgh: Williams and Wilkins, 1982.
  9. Duckworth AD, Jenkins PJ, Aitken SA, Clement ND, Court-Brown CM, McQueen MM. Scaphoid fracture epidemiology. J Trauma Acute Care Surg. 2012;72(2):E41-E45. doi:10.1097/ta.0b013e31822458e8
  10. deWeber, K. Scaphoid Fractures. Up to Date.
  11. Harrison W, Newton AW, Cheung G. The litigation cost of negligent scaphoid fracture management. Eur J Emerg Med. 2015;22(2):142-143. doi:10.1097/MEJ.0000000000000152

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