Shoulder/Upper Arm
Clavicle Fractures
Immobilization
- Sling and ACE wrap
- Pin sleeve to opposite shoulder (infants) or can provide gentle “figure 8” ACE wrap around shoulders
Follow Up
- All follow up with Ortho regardless of degree of angulation
- Management is usually non-operative, 90-95% are shaft fractures and do fine managed conservatively, surgeon preference
- No call to Ortho needed for any fractures unless there is at-risk skin or other anticipated problems*
*The fractures at risk are medial/proximal given the sternoclavicular joint. If risk of posterior displacement a CT scan should be considered, including a CTA for large vessel involvement. Very lateral/distal fractures can involve the AC and CC ligaments, and can required surgical intervention.
Mid-shaft clavicle fracture
Shoulder Dislocations
Immobilization
- Sling and swathe after reduction
Follow Up
- Follow up with Sports Medicine if first dislocation
- Follow up with Sports Medicine/Ortho if recurrent dislocation
Anterior shoulder dislocation
Proximal Humerus Fractures
Immobilization
- Sling and Swathe or
- Abduction Pillow if available
Follow Up
- Follow up with Sports Medicine if first dislocation
- Follow up with Sports Medicine/Ortho if recurrent dislocation
Also consider calling Ortho for>10 years old, >1cm separation, any rotational deformity, or intra-articular fracture
Proximal humerus fracture
Humerus Shaft Fractures
Immobilization
- Sling and Swathe
Follow Up
- Follow up with Ortho
- Call Ortho in the ED for rotational deformity
Humerus shaft fracture
Elbow Fractures
Supracondylar Fractures of the Humerus
Type 1 Non-displaced
Immobilization
- Long arm posterior splint
Follow Up
- Follow up with Ortho
Types 2, 3, & 4
- Type 2 is displaced in 1 plane
- Type 3 is displaced in 2 or 3 planes
- Type 4 has complete periosteal disruption
Immobilization
- Long arm posterior splint in position of comfort
Follow Up
- Call to Ortho, can discuss whether direct admit to Base is appropriate if at Liberty (concerns of adequate pain control from ED to admission)
Supracondylar Humerus Fracture Types
Olecranon
Immobilization
- Long-Arm Posterior Splint (elbow in slight extension)
Follow Up
- Follow up with Ortho
- Call Ortho in the ED if significant displacement
Olecranon fracture
Radial Head/Neck
Immobilization
- Long-Arm Posterior Splint (elbow at 90 degrees) with sling & swathe
Follow Up
- Follow up with Ortho
- Call Ortho in the ED if angulated >30 degrees or any dislocation
- GG >10 years with either angulation >10 degrees or displacement > 10% for neck fractures and >15 degrees for head fractures.
Radial head fracture
Radial neck fracture
Monteggia Fracture
Proximal ulna fracture with associated radial head dislocation
Immobilization
- Long-Arm Posterior Splint in position of comfort
Follow Up
- Call Ortho in the ED
Monteggia Fracture
Forearm Fractures
Distal Radius Buckle (Torus) Fracture
Immobilization
- Velcro wrist splint
Follow Up
- Follow up with Ortho to assure it isn’t a physeal fracture
Buckle Fracture
Radius & Ulna Fractures
Immobilization
- Sugar Tong splint
Follow Up
- Call Ortho in the ED for the following angulation:
- In age >10 years, over 10 degrees angulation
- The more proximal the injury, the less angulation is tolerated
- Any rotational deformity
- Less than 6 yrs old >20° distal metaphysis
- Any age >10°shaft) or
- Obvious deformity
- Otherwise follow up with Ortho
- 20-25 degree of flexion-extension angulation and 10 degrees of radial-ulnar deviation may remodel in younger kids (<10 years)
Both Bone Forearm Fractures
Galeazzi Fracture
Distal radius fracture with disruption of distal radioulnar joint
Immobilization
- Long-Arm Posterior Splint in position of comfort
Follow Up
- Call Ortho in the ED
Galeazzi Fracture
Hand Fractures
Scaphoid Fracture
Immobilization
- Thumb spica splint
Follow Up
- All definite or suspected follow up with Ortho
Scaphoid Fracture
First Metacarpal
Immobilization
- Thumb spica splint
Follow Up
- Call to Hand for any clinical deformity, any displacement, any rotational deformity, or angulation above acceptable limits
- Otherwise follow up with Hand
First Metacarpal Fracture
Second Metacarpal
Acceptable angulation: Neck <20°, Shaft <10°
Immobilization
- Radial gutter splint
Follow Up
- Call to Hand for any clinical deformity, any displacement, any rotational deformity, or angulation above acceptable limits
- Otherwise follow up with Hand
Second Metacarpal Fractures
Third Metacarpal
Acceptable angulation: Neck <30°, Shaft <10°
Immobilization
- Ulnar gutter splint
Follow Up
- Call to Hand for any clinical deformity, any displacement, any rotational deformity, or angulation above acceptable limits
- Otherwise follow up with Hand
Third Metacarpal Fracture
Fourth Metacarpal
Acceptable angulation: Neck <40°, Shaft <20°
Immobilization
- Ulnar gutter splint
Follow Up
- Call to Hand for any clinical deformity, any displacement, any rotational deformity, or angulation above acceptable limits
- Otherwise follow up with Hand
Fourth Metacarpal Fracture
Fifth Metacarpal
Acceptable angulation: Neck <50°, Shaft <30°
Immobilization
- Thumb spica splint
Follow Up
- Call to Hand for any clinical deformity, any displacement, any rotational deformity, or angulation above acceptable limits
- Otherwise follow up with Hand
Fifth Metacarpal Fracture
Finger Fractures
Phalangeal Neck Fracture
Any Finger
Immobilization
- Appropriate splint for the affected finger
Follow Up
- Call to Hand for any angulation, clinical deformity, especially rotational, or displacement
Thumb Fractures
Immobilization
- Thumb spica splint or cast
Follow Up
- Call to Hand for any rotational or angular deformity
Phalanx Fracture
First through fifth digits
Immobilization
- Appropriate splint for the affected finger
- Radial gutter for index/long
- Ulnar gutter for ring/small)
- Buddy Taping as indicated
Follow Up
- Call to Hand
- Any rotational or angular deformity
- Open fracture EXCEPT tuft
- Follow up with Hand:
7-10 days for tuft and buckle fx
All other injuries, 3-7 day