Fractures - Signup4.net

Fractures 101:
Fracture Management for
Primary Care
Dennis K-Borna, M.D.
Family & Sports Medicine, Kaiser Fontana
Bryan Wiley, M.D.
Orthopedics, Kaiser Fontana
X-ray Basics
• Can’t describe a fracture without at least
an AP and Lateral
• Consider oblique view if defect can only
be seen in one view
• Consider comparison view when dealing
with growth plate injuries
• Weightbearing views can be more helpful
when evaluating joint spaces
Lower Extremity
Toe Fractures
• Distal Phalangeal “Tuft”
Fractures
– Buddy tape, cast shoe,
stiff soled shoe until
pain-free.
– Pain control/RICE
– Consider referral for
displaced, comminuted,
>25% intraarticular
great toe tuft fracture
Toe Fractures
• Middle and Proximal
phalanx
– Reduce if displaced
– Buddy tape, SLWC,
cast shoe, stiff
soled shoe
– Consider referral if
unable to maintain
reduction or >25%
intraarticular
surface involved
Great Toe Fractures
• Weight bearing toe
• Immobilize
• Refer if:
– Displaced
– Intraarticular >25%
– Failed reduction
– Fracture-dislocation
Metatarsal Shaft Fractures
• Non-displaced
– Posterior splint 3-5 days >> SLWC/CAM walker 2-3
weeks followed by cast shoe another 3-4 weeks
– X-ray at 7 days and at 4-6 weeks to confirm healing
• Displaced
– Reduce/Mold
– Bivalved well-molded cast x 3-5days >> SLNWBC 23wks followed by SLWC 3-4wks.
• Be wary of cast fit, compartment syndrome
• Icing, elevation is extremely important for the
first 2-3 days
Metatarsal Fractures
• Red Flags/Reasons to refer
– Displaced 1st MT fracture
– Vascular injury/Compartment syndrome
– Multiple metatarsal fractures
– Fracture near the metatarsal head
• tend to get plantar displacement
– Metatarsal base fractures
• inherently unstable, associated with other injuries
like Lisfranc
– Fracture-dislocations
5th Proximal MT fracture
• Jones fracture
– Fracture through the
proximal diaphysis
– Heal very poorly
– Treatment
• NWB/SLC (12-20wks)
• ORIF (Screw fixation)
• Metaphysealdiaphyseal
– Similar to Jones fx but
more proximal and
tend to heal better.
5th Proximal MT Fractures
• 5th prox MT styloid
avulsion fracture
– Heal very well
– Cast shoe, CAM
walker, or SLWC for
2wks
– Consider referral if
displaced > 3mm
Lisfranc Injury
Anatomy/Mechanism
Am Fam Physician. 1998 Jul;58(1):118-24.
Lisfranc Fracture Dislocation
Lisfranc
• Focus on tarsal-metatarsal alignment
• Compare weightbearing and
nonweightbearing views
• Look closely at widening between the 1st
and 2nd metatarsals
Lisfranc
Lisfranc Treatment
• Almost always refer
• Most will require
internal fixation to
avoid long term
deformity (below)
Should
be
referred
Ottawa Ankle Rules
• X-rays should for any ONE of these:
– There is pain over the medial or lateral
malleolus
– There is pain over the navicular or proximal
5th metatarsal
– The patient was unable to bear weight (of 4
or more steps) at the time of injury and at
the time of exam
X-rays
• AP, lateral, and mortise views are necessary
Mortise View
Isolated Malleolar Fractures
• Avulsion fractures
– Treat tiny avulsions like a
severe ankle sprain
– Stirrup splint for 3-5 days
– RICE!!!
– SLWC or cam walker for
4-6 weeks*
Isolated Malleolar Fractures
• Follow-up in 2-week intervals to assess healing
• XIP is OK in most cases
• Be wary of patients who will not heal well
– Osteopenic patients
– Older patients
– Smokers
– Diabetics
• After immobilization is completed, start on
ROM exercises and calf stretches, followed by
ankle strengthening exercises
Bimalleolar and Trimalleolar
Fractures
• Usually occur as a result of eversion +/external rotational force
• These are inherently unstable fractures
and should be referred
Trimalleolar Fracture
Distal Fibula Fractures
• Most are stable, and can be treated with a
SLWC or cam walker
• Generally, the further away from the joint a
distal fibula fracture is, the higher the risk of
instability
• Watch for ligamentous instability
• Fractures that cross the joint line may likely
need to be nonweightbearing and should be
followed closely
Distal Fibula Fractures
Distal Fibula Fractures
Stable Fractures
• Isolated to the lateral, medial, or
posterior malleolus
• Non-displaced
• Not associated with a ligamentous injury
Ankle Fractures to Refer
• Bimalleolar or trimalleolar fractures
• Malleolar fracture on one side with an
associated ligament disruption on the
opposite side
– Often will be evident on mortise view
• Posterior malleolar fractures with >2mm
displacement
Pediatric Fractures
• Get comparison views!
• Ligamentous injuries are rare in children
because the ligaments are stronger than
the growth plate
• Distal tibia fractures are more common
than in adults (especially in toddlers)
Growth Plate Fractures
Growth Plate Fractures
Growth Plate Fractures
Pediatric Ankle Fractures
• Most common fracture is a Salter-Harris I
fracture of the distal fibula
– the physis is the weakest biomechanical
structure in the bone-tendon-ligament
chain
– this injury is the essential equivalent to a
lateral ankle sprain in a skeletally mature
individual
– x-rays are often normal
– short leg walking cast or cam walker for 3–4
weeks
Pediatric Distal Fibula Fractures
• Nondisplaced Salter I and II fractures can
be treated with a SLWC for 3-4 weeks
• Refer displaced fractures or fractures of
Salter III or higher
Pediatric Distal Tibia Fractures
• Salter I fractures (relatively rare) can be
treated with a SLWC for 4 weeks
• Salter II fractures often need a long-leg cast
with 30 degrees of knee flexion for 3 weeks,
followed by a SLWC for 4 weeks
• Salter III fracture and higher should be
referred
Fibular Shaft Fractures
• Usually a result of a direct blow to the lateral leg
• Fibula is a nonweightbearing bone, and
fractures are usually stable
• Watch for ankle instability, particularly in cases
where the injury is from ankle external rotation
• Most can be treated with a stirrup splint and
nonweightbearing for 3-5 days, followed by
Sarmiento brace, SLWC, or cam walker for 4
weeks*
Fibular Shaft Fractures
Tibial Shaft Fractures
• Nondisplaced fractures can be managed by primary
care, but most others should be followed by
Orthopedics
• <5mm displacement
• <5 degrees of angulation
• Initial treatment involves long leg posterior splint with
NWB and strict elevation
• Long-leg cast for 4-6 weeks with knee at 5 degrees of
flexion and ankle at 90 degrees of flexion
• Short-leg walking brace for 10-14 weeks
Tibial Shaft Fractures
Toddler’s Fractures
• Somewhat common in 2-3 year-old children
who are learning to walk
• Frequently occur as a result of a torsional load
at the foot
• Often present without history of distinct injury,
and simply with a reluctance to bear weight
• Don’t forget to examine the hip, thigh, and knee
Toddler’s Fractures
Toddler’s Fractures
Immobilize in a longleg cast for 3-4
weeks
Re-check with XIP at
2 weeks
Weightbearing as
tolerated
subsequently
Toddler’s Fracture
Patella Fractures
• Can involve significant disruption of the
extensor mechanism
• Nondisplaced fractures can be treated in
a knee immobilizer for 5-7 days with
NWB, followed by a cylinder cast*
• Displaced fractures should be referred
immediately
Patella Fracture
Upper Extremity
Clavicle Fractures
•
•
Middle third: 70-80%
Distal third: 15-28%
•
•
Involvement of coracoclavicular
ligaments
Proximal third: <5%
•
Sternoclavicular dislocation,
intrathoracic or neurovascular injury
(posterior displacement)
Clavicle Fractures
Clavicle Fractures
Clavicle Fractures
Clavicle Fractures
Clavicle Fractures – Primary Care
• Sling immobilization for comfort
• Figure-of-eight brace for displaced fractures
may be better for re-alignment
• Healing time:
– 3-6 weeks in children
– 6-12 weeks in adults
– An additional 1-2 months of full contact avoidance
www.stcroixortho.com
Clavicle Fractures -- Orthopedic
• Complete displacement, especially with
shortening
• Proximal fracture with any displacement
• Symptomatic nonunion
Humerus Fractures
• Predominantly older patients
• Osteoporosis, less severe trauma
• Children, young adults usually
fracture distal humerus with severe
trauma
Proximal Humerus Fractures
Treatment
•
Sling or shoulder immobilizer if
minimal angulation/displacement
•
Collar and cuff sling if more than
20 degrees of angulation
Collar and cuff sling
Proximal Humerus Fractures
•
Orthopedics consult:
• Angulation of greater than 20 degrees
in active/athlete
• Neurovascular injury
• Distortion of bicipital groove
• Fracture-dislocation
• Displaced Neer types
Neer classification: 4 parts
Midshaft Humerus Fractures
•Direct blow or bending force
•FOOSH, fall on elbow, violent muscle
contraction
•Torsional forces (long spiral)
•Think child abuse
Midshaft Humerus Fractures
Treatment
www.medicalmultimediagroup.com
Midshaft Humerus Fractures
Treatment
• Orthopedics consult:
• Neurovascular injury
• Fracture at or below lower third of
humerus
• Suspected non-union
• Pathologic fracture
• Associated elbow injury
Elbow Fractures
• It is important to recognize these fractures
which can be subtle
• Comparison view x-rays can be very helpful,
especially in children
• Many fractures should be managed by
Orthopedics
• Nondisplaced fractures can be managed by
Primary Care
Normal Elbow
Normal Elbow Alignment
Elbow: abnormal anterior humeral
lines
Elbow Fracture
Elbow Fracture
Radial Head Fractures
• Look for posterior fat pad in the absence
of other findings in the elbow
• Sometimes a faint lucency or fracture
line in the radial head can be seen
• Tenderness at the radial head
• DO NOT OVER-IMMOBILIZE!!
• EARLY R.O.M. IS IMPORTANT
Radial Head Fracture
Radial Head and Neck Fractures
Treatment
• Long arm posterior splint or sling
• Close follow-up within a week
• Early ROM exercises as tolerated
Radial Head and Neck Fractures
Treatment
• Orthopedics consult indications:
• Fracture-dislocation
• Mechanical block to motion
• > 2mm displacement
• > 1/3 articular surface involved
• > 3mm depression
• > 30 degrees angulation
• Severe comminution
Supracondylar /Transcondylar
Fractures
• Can be managed in Primary Care if there is
no displacement present
• Long arm posterior splint
• ROM at 2 weeks
• Immobilize x 6 weeks or until adequate callus
present
• 8-10 weeks to get motion back
• Orthopedics consult:
• Neurovascular compromise (emergent)
• Any displacement
Supracondylar Fracture
Distal Radius Fracture:
Buckle (Torus) Fracture
Distal Radius Buckle Fracture
• Pay close attention to the lateral view
Buckle Fracture
Buckle Fracture
Treatment
• Volar splint initially for 3-5 days if swollen
• Short-arm cast for 4 weeks
• OK to start with long-arm immobilization
for 1-2 weeks if there is significant pain
with pronation/supination
Distal Radius Fracture:
Transverse Fracture
Distal Radius Fracture
Treatment
• Double sugar-tong splint with wrist in slight
neutral and ulnar deviation; elbow flexed at
90 degrees
• Follow-up in 3-5 days
• Long-arm cast subsequently for 3-4 weeks,
then short-arm cast for 2-4 weeks
Distal Radius Fracture:
Colles’ Fracture
Distal Radius Fracture
Treatment
• Orthopedic referral:
– Need for reduction
– Intraarticular involvement
– Comminution
– Newly angulated
– Neurovascular symptoms
Scaphoid Fracture
Get a scaphoid view
Scaphoid Fracture
Scaphoid Fracture
Scaphoid Fracture:
Initial management
•
Suspected Fracture
•
•
Short-arm thumb spica cast or splint and recheck in 1-2 weeks
Non-displaced Fracture:
•
•
Distal 1/3: short arm thumb spica cast/splint
Middle/proximal 1/3: long-arm thumb spica
cast/splint
•
may change to short-arm later (at 6 weeks); should be
pain-free with pronation and supination
Scaphoid Fracture:
Definitive treatment
• Distal 1/3:
• 4-6 weeks immobilization
• 6-8 weeks to heal
• Middle 1/3:
• 10-12 weeks immobilization
• 12-14 weeks to heal
• Proximal 1/3:
• 12-20 weeks immobilization
• 18-24 weeks to heal
Scaphoid Fracture
•Refer to Orthopedics for:
•Any displaced fracture
•Consider for nondisplaced proximal
•Nonunion
•Early signs of avascular necrosis
Scaphoid Fracture:
Orthopedic treatment
• Complicated fractures such as non-union,
AVN, or displaced fractures can be treated
with one or more of the following:
– further immobilization
– electrical stimulation
– bone grafts with or without vasculature
– pinning
Metacarpal Fractures
Metacarpal Fractures
• Nondisplaced fractures can be managed in
Primary Care
• Gutter or Burkhalter splints
• Re-check within 1 week
• ROM exercises after 4-6 weeks immobilization
• Avoid contact sports for another 4-6 weeks or
use orthotic protection
Metacarpal Fractures
radial gutter splint
Burkhalter splint
ulnar gutter splint
Metacarpal fractures:
Indications for referral
• Head
• Displaced or comminuted fractures
• Neck:
• Angulated or displaced fractures of 2nd or 3rd
metacarpals
• 4th metacarpal if >30 degrees angulated
• 5th metacarpal if >40 degrees angulated
• Any malrotation, unacceptable angulation to
patient, inability to hold reduction, malunion with
painful grip or pseudoclawing
• Shaft
Metacarpal fractures:
Indications for referral
•
•
•
•
•
Malrotation
Shortening >5mm
New displacement/inability to maintain reduction
Comminution
Fracture of more than one metacarpal
•
•
•
•
All 5th metacarpal base fractures
Malrotation
Subluxation/dislocation of CMC joint
New displacemment/inability to maintain
reduction
• Base
Phalangeal Fractures
• Nondisplaced fractures of the middle and
proximal phalanges can be managed in
Primary Care with buddy taping or gutter
splinting
• Distal phalangeal fractures can be managed
with a protective splint, with the DIP in
extension
Phalangeal Fractures
Indications for referral
• Proximal or middle phalanx
– Rotational deformity
– Uncorrected angulation
– Oblique or spiral fractures
– Intraarticular fractures
• Distal phalanx
– Angulated fractures
– Displaced transverse fractures
– Nonunion
Thank You
References
• Boyd, Anne S, Holly J Benjamin, and Chad Asplund. “Splints and
Casts: Indications and Methods.” American Family Physician 80, no.
5 (September 1, 2009): 491–499.
• Hatch, Robert L., and Eiff, M. Patrice. Fracture Management for
Primary Care. 3rd ed. Elsevier, 2011.
• http://huntingtoncomfortshoes.com/prescriptionproducts/prescription-braces/tibial-fracture-orthosis.html.
• Leggit, Jeffrey C, and Christian J Meko. “Acute Finger Injuries: Part I.
Tendons and Ligaments.” American Family Physician 73, no. 5
(March 1, 2006): 810–816.
• Leggit, Jeffrey C, and Christian J Meko. “Acute Finger Injuries: Part II.
Fractures, Dislocations, and Thumb Injuries.” American Family
Physician 73, no. 5 (March 1, 2006): 827–834.
• Rubin, Aaron L. Sports Injuries and Emergencies: A Quick Response
Manual. McGraw Hill Professional, 2003.