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fracture fragment as the reference and another line along the distal fracture
fragment. The angle measured between the axes of those two lines describes the
degree of angulation of the fracture, conventionally reported using the direction
of the apex of the fracture (e.g., in Fig. 111.5 the femur fracture is medially
angulated).

FIGURE 111.5 Diagrammatic representation of fracture deformities: displacement (A ),
angulation (B ), and overriding with shortening (C ).

Indications for orthopedic consultation will vary with the ability and
experience of the emergency clinician and availability of the orthopedist.
Emergent orthopedic consultation is required to evaluate open fractures, those
that are significantly displaced, or if neurovascular compromise is present.
Orthopedic consultation is also recommended during ED visits for pelvic
fractures (other than avulsions), spinal injuries, and dislocations of major joints
(other than the shoulder). Referral to see an orthopedist as an outpatient within 24
to 48 hours is recommended for any growth plate or intra-articular fractures that
have more than 2 to 3 mm of displacement and for fractures of the lower
extremity long bones, as long as the extremity is neurovascularly intact and pain
is adequately controlled. Physeal injuries begin healing quickly; therefore, urgent
orthopedic referral is important to ensure adequate reduction of any displaced