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computed tomography (CT) is often used. Although not commonly used in the
ED, magnetic resonance imaging (MRI) is also used for the evaluation of physeal
injuries as well as the diagnosis of avulsion and stress fractures, as it can visualize
cartilaginous and soft tissue structures as well as osseous ones. The use of
ultrasound in the ED setting is also expanding, both for diagnostic purposes as
well as to guide closed fracture reduction.
Immobilization. Paired with pain control, immobilization is fundamental to the
initial treatment of fractures. Plaster or fiberglass casts/splints or prefabricated
splints may be used to immobilize the fractured bone as well as the joints above
and below the injury. Immobilization provides pain control and helps to prevent
further injury. The application of several layers of padding material before the
splint or cast is placed is important for comfort and to decrease neurovascular
compromise from swelling of the extremity (see Chapter 130 Procedures , section
on Splinting of Musculoskeletal Injuries). The decision for the emergency
clinician to splint or place a circumferential cast depends on the degree of actual
or anticipated swelling, the risk for compartment syndrome, and the training of
the provider.
Pain Control. At triage, pain management can begin with oral analgesics (e.g.,
ibuprofen, acetaminophen), either given alone or in combination. For injuries
with more significant pain, intranasal fentanyl or intravenous narcotics may be
administered. In addition, local and regional anesthesia blocks may be used based
on the injury location. When fracture reduction is performed in the ED,
procedural sedation with nitrous oxide or intravenous agents should be used by
appropriately trained personnel (see Chapter 129 Procedural Sedation ).
Orthopedic Consultation and Referral. When consulting the orthopedic
surgeon, the emergency clinician needs to present accurate and descriptive
information about the injury so the orthopedist can make appropriate treatment
recommendations. The initial communication should include patient’s age and
gender, mechanism of injury, anatomic location, neurovascular status, and extent
of soft tissue injury. The radiographic description should note the anatomic
location of the fracture, the type of fracture (e.g., transverse, spiral, oblique),

amount of displacement, degree of angulation, shortening, or malrotation, degree
of comminution, and the extent of involvement of the joint and physis (e.g.,
Salter–Harris classification) ( Fig. 111.5 ). Displacement for long bone fractures
is commonly described using the approximate percentage of the shaft width
displaced. Angulation is measured by drawing one line along the proximal