If you have concerns about following these guidelines please consult your A&E senior or the Orthopaedic Registrar on-call.
All patients referred to the Adult Virtual Fracture Clinic require x-rays except calf muscle tears and suspected Achilles tendon injuries
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 the referral does not fit our criteria it may be declined and returned to you via email
Please refer any patients under 16 to the Paediatric Virtual Fracture Clinic.
Fracture
Subcategory
A&E Management
Polysling
Analgesia
On-line referral to virtual fracture clinic
Refer to Ortho on-call team
Polysling/double collar and cuff
Analgesia
On-line referral to virtual fracture clinic
Polysling/double collar and cuff
Analgesia
On-line referral to virtual fracture clinic
Refer to ortho reg on call
Polysling or double loop collar & cuff
Analgesia
Contact GP or self-refer to MSK partnership if not settling with 6 weeks
Polysling or double loop collar & cuff
Analgesia
Contact GP or self-refer to MSK partnership if not settling with 6 weeks
Polysling or double loop collar & cuff
Analgesia
On-line referral to virtual fracture clinic
Reduce
Polysling
Analgesia
On-line referral to virtual fracture clinic
Reduce
Polysling
Analgesia
On-line referral to virtual fracture clinic
Shoulder fracture dislocation
Post reduction
Polysling
Analgesia
On-line referral to virtual fracture clinic
Refer to Ortho on-call
Refer to Ortho on-call for advice before reduction. A proximal humeral fracture must be excluded.
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
Fracture
Subcategory
A&E Management
Treat hypovolaemia
Refer Ortho on-call
Refer Ortho on-call
For reduction in theatre
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 VFCDischarge
If ongoing issues to reattend ED or see GP
Further imaging to exclude fracture
If no fracture discharge
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
Mild soft tissue knee injury
Reassure likely to resolve with time
Mobilise FWB
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
Refer Ortho on-call
Tubigrip or cricket pad splint
On-line referral to virtual fracture clinic
Refer as locked knee to Ortho on-call
Patella Fracture
Cricket pad splint
Full weight bearing
Online referral to virtual fracture clinic
Refer to Ortho on-call
Patella dislocation
Reduce
AP, Lateral & Skyline x-ray
Cricket pad splint
Full WB, crutches if needed
On-line referral to virtual fracture clinic
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
VFC will decline any referral for a tibialplateau fracture
Tibia
Refer Ortho on-call
Above knee backslab
Refer Ortho on-call
Above knee backslab
Refer Ortho on-call
Reduce & above knee backslab
Refer Ortho on-call
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
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
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
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
Weber C
No talar shift
Black boot
Refer Ortho on-call
Weber C
Talar shift
Reduce
Backslab
Refer Ortho on-call
Reduce if needed
Backslab and CT scan
Refer Ortho on-call
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
Weight bear as tolerated.
On-line referral to virtual fracture clinic
Isolated medial malleolus
Large fragment - undisplaced
Refer Ortho on-call
Isolated medial malleolus
Displaced
Refer Ortho on-call
CT
Backslab
Refer Ortho on-call
Black boot
Weight bear as tolerated
On-line referral to virtual fracture clinic
Black boot
On-line referral to virtual fracture clinic
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
Black boot
Full weight bear
Online referral to virtual fracture clinic
Tarsal fractures - Undisplaced
(Navicular, cuboid, cuneiforms)
Black boot
NWB
On-line referral to virtual fracture clinic
Backslab
CT
Refer Ortho on-call
Lis-franc fracture / dislocation
Including suspected on basis of mechanism / swelling / planter bruising
CT
Backslab
Refer Ortho on-call
Metatarsal fractures
CT scan for VFC review
Black boot
Weight bear as tolerated
On-line referral to virtual fracture clinic
CT
Blackboot
NWB
Refer Ortho on-call
Black boot
Heel weight bear
On-line referral to virtual fracture clinic
Black boot
Weight bear as tolerated
On-line referral to virtual fracture clinic
Black boot
Weight bear as tolerated
On-line referral to virtual fracture clinic
Black boot
Weight bear as tolerated
On-line referral to virtual fracture clinic
Black boot three weeks
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 patientcare plan and advise will only be contacted if a change in management is required
Black boot/loose shoe
If boot given-Complete VTE Risk Assessment
Weight bear as tolerated
Online referral to virtual fracture clinicand give patientcare 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
Black boot three weeks
Weight bear as tolerated
Discharge
Reduce
Black boot
Weight bear as tolerated
Online referral to virtual fracture clinicand give patientcare 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
Neighbour strap two weeks
Weight bear as tolerated
Discharge
Reduce
Neighbour strap two weeks
Weight bear as tolerated
Dischargeunlessreduction is unstable. If unstable, online referral to virtual fracture clinic.
