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