Extremity Fracture Clinical Pathway — Emergency Department

Immobilization Devices/Cast Types by Injury

These are guidelines for immobilization. Each fracture is different and treatment may be individualized after consultation with orthopedics.

Injury/Indications	Immobilization Device	Comments
Buckle Fracture	Velcro splint	Simple buckle fractures that have no cortical break or angulation can be placed in a Velcro splint with PCP follow-up in 4 wks All others should have an ortho consult
Greenstick fracture Nondisplaced wrist or hand fracture	Short arm cast	Call ortho for any degree of angulation
Both bone forearm fracture Radius or ulna fracture requiring reduction Elbow fracture Monteggia fracture Radial head or neck fracture Young child	Long arm cast	All fractures going to the OR should be splinted in the ED Short arm cast may be appropriate in some cases per Ortho recommendations Young children can slip out of short arm cast (less muscle mass) so get long arm cast regardless of injury
Scaphoid fracture or snuffbox tenderness	Short arm cast with thumb spica
Foot fracture (if pain with CAM boot) Ankle fracture without reduction	Short leg cast
Distal femur fracture non-displaced (metaphyseal and below); Tibia fracture Ankle fracture requiring reduction	Long leg cast	Short leg splint may be appropriate if concern for ongoing swelling after ankle reduction
Femur fracture in toddlers	Spica cast	Admit to Ortho for placement
Presumed toddler fracture with negative X-ray Nondisplaced fracture Stable, non-displaced foot fractures Foot or ankle injuries or severe sprains with negative X-rays Stable, non-displaced fracture of the distal fibula including SH1 SH1 or non-displaced buckle fractures of the distal tibia	CAM boot	If the X-ray for a toddler's fracture shows any fracture widening, angulation or displacement, call Ortho

©2024 by Children's Hospital of Philadelphia, all rights reserved.
Use of this site is subject to the Terms of Use.

The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.