ALWAYS CALL (even overnight)

• Open Fractures (long bone—not fingers toes etc.)

• Impending Open Fractures (skin tenting–meaning skin is blanched and immobile)

• Pathologic Fractures (we do NOT have orthopedic oncology at MSMC, so if these patients get admitted without our prior knowledge it’s very hard to transfer)

• Irreducible Fractures/Dislocations

• Poly-Trauma (2+ long bone fractures)

• Any pelvis fracture that is not an LC1 pelvic ring (sacrum + sup/inf pubic ramus)

• Any acetabular fracture 

• Any fracture-dislocation

• Any neurovascular compromise

• Concern for Compartment Syndrome

• Young (<50 years old) Femoral Neck Fractures

• Septic Joints

**After 10-11pm, just please consider that on-call surgeons typically have a full clinic or OR day the following day. We are always available to answer questions, but as a courtesy, phone calls after 11pm should really (as much as possible) be reserved for the above scenarios or true orthopedic emergencies.**

RED FLAGS = Call/Text before sending

1. UPPER EXTREMITY

   1. Fingers & Hand (Carpal Bones) → Hand Call

   2. Distal Radius/Ulna

      1. Hematoma Block, reduce, splint with outpatient follow up

      2. Red Flags→ Concerns for acute carpal tunnel syndrome– N/T thumb/index/middle

   3. Mid-Shaft Radius OR Ulna

      1. Sugar-tong splint with outpatient follow up

      2. Red Flags→ both bone forearm fractures high risk for compartment syndrome

   4. Radial Head

      1. Sling and outpatient follow up

      2. Red Flags→ exceptionally rare even in grossly displaced fractures

   5. Olecranon Fractures

      1. Splint in slight extension and outpatient follow up 

      2. Red Flags→ rare

   6. Distal Humerus

      1. Sling and outpatient follow up

      2. Red Flags→ ulnar/radial nerve palsy (neurovasc compromise)

   7. Humeral Shaft

      1. Sling or Coaptation Splint (splinting sometimes dependent on tech availability)

      2. Red Flags→ always check radial nerve

   8. Proximal Humerus

      1. Sling and outpatient follow up

      2. Red Flags→ fracture-dislocations (if any concern MUST have an axillary/Velpeau XR or if not possible→ CT shoulder)

   9. Clavicle/AC joint

      1. Sling and outpatient follow up

      2. Red Flags→ Gross displacement with skin tenting (skin is blanched and immobile at apex of fracture site), Dislocation of sternoclavicular joint

   10. Scapular Body

       1. Sling and outpatient follow up

       2. Red Flags→ These are high velocity fractures, low threshold for trauma eval

   11. Scapula–Glenoid

       1. CT to assess potential for instability of the shoulder joint (these are typically from fracture-dislocations so with a large enough glenoid fracture these may be irreducible)

       2. Sling and outpatient follow up after ^^

   12. Periprosthetic Fractures or Dislocations

       1. Shoulder– 

          1. Dislocation→ if one of us did the shoulder replacement, call before attempting to reduce. 

          2. Fracture→ sling and discharge

       2. Elbow–

          1. Dislocation→ if one of us did the elbow replacement, call before attempting to reduce

          2. Fracture→ sling and discharge

2. LOWER EXTREMITY

   1. Toes→ Podiatry

   2. Metatarsals

      1. CAM boot/Post-Op Shoe and outpatient follow up

      2. Red Flags→ Multiple metatarsal fractures, especially proximal fractures should be CT’d before discharge

   3. Talar Neck/Body

      1. CAM boot and outpatient follow up NWB

      2. Red Flags→ dislocations of the talar body are extremely difficult to reduce. Low threshold to call.

   4. Ankle Fractures

      1. Splint and outpatient follow up

      2. Red Flags→ irreducible fractures despite appropriate anesthesia, skin tenting. 

   5. Tibia/Fibula Shaft 

      1. Splint and admit

      2. Reasonable to call before admitting. Some of these are high velocity and high risk for compartment syndrome and should be sent to a trauma facility. 

   6. Tibial Plateau

      1. CT all of these even if discharging. XRs are not enough to classify these. 

      2. If bicondylar→ call, some of these need to be transferred to trauma centers

      3. Unicondylar→ knee immobilizer, NWB, outpatient follow up

   7. Patella

      1. Knee immobilizer and discharge WBAT

   8. Distal Femur

      1. CT all of these and admit

      2. Knee immobilizer, NWB, NPO at midnight

   9. Femoral Shaft

      1. Dedicated hip XRs

      2. Admit, NWB, NPO at midnight

      3. Reasonable to call before admission– if high energy may need transfer to trauma center

   10. Hip Fractures: femoral neck, intertrochanteric, subtrochanteric 

       1. Red Flag→ Age < 50 years

       2. Admit, NWB, NPO at midnight

       3. Hip + Femur Radiographs

       4. These typically don’t need to be a phone call regardless of time of night.

   11. Acetabular Fractures:

       1. Just about all of these need to be sent.

       2. EXCEPT: isolated anterior wall fractures

   12. Pelvis Fractures

       1. Just about all of these need to be sent 

       2. EXCEPT: LC1 ipsilateral superior/inferior pubic ramus + sacrum. These are stable and WBAT, nonsurgical

   13. Native Hip Dislocations

       1. Very rare, send to trauma center ASAP

   14. Native Knee Dislocations

       1. Very rare, CTA and consult vascular high risk for popliteal artery dissection

       2. Not to be confused with a patella dislocation.

   15. Prosthetic Hip Dislocations

       1. If any of us did the replacement, call before reducing

       2. If reducible OK to discharge with knee immobilizer

   16. Prosthetic Knee Dislocations

       1. Very rare, call 

   17. Periprosthetic Femur fractures around a THA or TKA

       1. OK to admit, NWB, NPO at midnight

       2. Not necessary to call first. We have plenty of surgeons who can take care of periprosthetic femur fractures even if they aren’t on call. 

   18. Concern for Periprosthetic (hip or knee) Infections

       1. If any of us did the replacement, do not aspirate. Call first. 

       2. Our preference is that no prosthetic hip or knee is aspirated in the ER