11/5/14. I will try to make this painless. Great, a Fracture, Now What? Objectives. Basics for Fracture Workup. Basics for Fracture Workup

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1 Great, a Fracture, Now What? I will try to make this painless Mary Greve MS, PA-C Department of Orthopedic Surgery Trauma Team University of Iowa Hospitals and Clinics Mary-Greve@uiowa.edu Pager 2121 Objectives Lots of learners in clinic have the same concerns and questions l How do I describe fractures competently? l What can I take care of? l What needs to be referred? l Urgency We will cover some of the most common fractures that can be managed by PCPs History Basics for Fracture Workup l Mechanism of injury? Tells you what to look for l Timing of injury? New or old, has the patient been weight bearing etc. Basics for Fracture Workup Physical Exam l Inspection is much of exam Ecchymosis, swelling, skin exam, deformity, open fracture l Neurovascular Checks l Exam of joints above and below l Ok to ask for active range of motion but passive range of motion should not be done until x-rays are done X-rays Basics of Fracture Workup l Always get at least 2 views of the injured area (at 90 deg angles to one another) If you are unsure which films to get, call ortho or radiology X-rays of joint above and below injury if injury is to a long bone (ex: forearm fractures need elbow and wrist films) 1

2 Distal Radius Fracture Basics of Fracture Workup Treatment l What can you do acutely? l Can the patient wait to see ortho? l Does the patient need to see ortho? Always important to get two views at 90 deg angles to one another Giving an Expert Presentation When calling ortho, be able to tell us which films you have and try your best to describe the fracture l Start with which bone is injured l Is it an open or closed injury? (compound is an old term) l Where is the injury? Proximal end, midshaft, distal end l How badly is it broken? (simple or comminuted) l Is it displaced? (angulated, translated, shortened) If so, how much? Does it go into the joint, if so, which one? Other things to communicate l Are there other injuries (head, chest, belly, limb)? What is the condition of the patient? l Your limitations (film quality, lack of casting/ splinting etc.) How You Might be Feeling Now 2

3 Here s the Pattern What Xrays do you have? Name of bone broken Describe the fracture pattern l Orientation (transverse, oblique, spiral) l Comminution (none, some, wow, that s bad! ) l Translated l Angulated l Rotated l Shortened Review of Terms Review of bone anatomy (physis, metaphysis, diaphysis etc) Junction of two Pattern/Orientation Review of Terms Translation where distal fragment is relative to proximal fragment, described in millimeters or by % of bone width and direction l Here the bone is translated about 50% laterally Review of Terms Translation What about this one? Translated about 75% Review of Terms Angulation where is apex pointing? l Anterior? Posterior? Dorsal? Volar? Valgus? Varus? lgus alignment -> 3

4 Angulation Example of apex anterior angulation Rotation (just know it s rotated!) Review of Terms Shortening how much do fragments overlap? l Most commonly done in cm Pearls: Just the Facts Ma am Pearls: Just the Facts Ma am Here s the thing, we just want to know if we have to come and see the patient. So, tell us: l Name of broken bone and general area l Is it displaced? If so, is it mild, moderate, or yikes! Be able to fill in the gaps if requested. How would you describe this? AP view of the forearm which shows both the wrist and elbow (adequate films) There are fractures of both the radius and ulna at the junction of the distal 1/3 and middle shaft Oblique Not comminuted Translated 100% Maybe rotated? Shortened a bit What else??? How would you describe this? Lateral view confirms what you ve seen on the AP Not a perfect lateral l In this case, don t torture the patient with another attempt 4

5 Lets Try Another One Lets Try Another One AP view of humerus Includes shoulder and elbow joints (good quality) Midshaft humerus fracture l Transverse l Simple (not comminuted) l Translated 25-50% l No rotation l No shortening Lateral view that does not include shoulder Midshaft humerus fracture, transverse, simple (as before) Apex anterior angulation (25-30 deg) Do you feel like this kid? On to the fractures. Very common l 5% of all fractures seen in Emergency Department Mechanism l Usually fall onto an outstretched arm or direct trauma to the area Physical Exam l Swelling, ecchymosis, lump at the fracture site l Deformity is fairly common l Motion can be uncomfortable l Skin and neurovascular checks, listen to lungs (3% with pneumothorax) 5

6 Many clinicians worry about skin compromise l Not typically an issue with clavicle fractures Like always, better safe than sorry l Refer to Ortho if concerned or if skin is blanched Clavicle Fracture Xrays Xrays l AP Clavicle view l It s reasonable to get a full shoulder series to rule out other injuries as well AP, Grashey (true AP), Axillary (lateral view of shoulder) AP clavicle AP shoulder Grashey Axillary Midshaft Fracture location l 85% are midshaft l 10% are in the distal 1/3 l 5% are in the proximal 1/3 6

7 Midshaft l About 70-80% will go on to heal with simple treatment Surgery is a hot topic these days l Midshaft, shortened fractures *may* do better with ORIF Typically, conservative treatment is reasonable l Sling for comfort Figure of Eight rarely used; patients don t like them l Discourage repetitive overhead activities l Discourage NSAIDS (Tylenol or opiates instead) l Refer if you are uncertain about surgical appropriateness Figure of Eight Brace (patients won t like you but they ll think you re smart!) Ortho referral is not absolutely necessary if you feel comfortable treating l Won t see much healing before 6 weeks on plain films l If patient is feeling better at that point, chances are good he/she is healing Ortho referral can be made otherwise l Patient to see us 1-2 weeks after injury CYA Discuss possibility of nonuion (up to 30% in shortened, significantly displaced fracture) with patients l It s ok to take the wait and see approach l THERE WILL BE A LUMP IF IT WAS DISPLACED! NSAIDS are thought to delay bone healing, avoid if possible with fractures l APAP ok l Be reasonable about this (ok for headaches etc) Distal Clavicle Fracture 7

8 Distal Questions so far? If nondisplaced, simple treatment with sling If very displaced, the nonunion rate can be high - refer Radial Head Fractures Radial Head Fractures Isolated Radial Head Fractures Make up about 20% of all elbow injuries l Most common elbow fracture in adults Mechanism l Fall onto an outstretched hand Isolated Radial Head Fracture Physical Exam l Sore, painful elbow l May or may not be ecchymotic l Usually can t see much swelling in an elbow on exam l Painful movement Especially pronation/supination Almost never able to extend completely l Pain over radial head on palpation 8

9 Xrays Isolated Radial Head Fractures l AP, Lateral and Radial Head views Always consider radial head views on x-ray exam of any elbow Isolated Radial Head Fractures Lateral of the elbow Radial head view AP elbow Lateral elbow Isolated Radial Head Fractures Fat Pad Sign Can be difficult to see on Xrays => occult fracture If suspicious, put in sling and re-xray in 7-10 days The type you will most often see in a primary care setting is a non displaced fracture (to the right) Isolated Radial Head Fractures Treatment l Sling for 2-3 days for comfort only l After 2-3 days, the sling should come off for range of motion (flex, ext, supination, pronation) Don t let elbows get stiff!! If still stiff at 2-3 weeks, consider PT l Low level opiate for a week or two Tylenol is ok, NSAIDS should be avoided l Return to activities as tolerated When to see ortho? Isolated Radial Head l If you are comfortable treating non displaced fractures, no referral is necessary l If the fracture is displaced, or you are uncomfortable, refer within the first 3-4 days Ortho will reinforce early range of motion and removal of sling. This is not emergent so it s ok to wait longer to see ortho if necessary. GET THEM MOVING! 9

10 Pearls Doing ok? Fractures may not show up at the time of injury but will likely be more apparent days later l Consider repeat films in someone with clinical suspicion of fracture with no x-ray evidence Metatarsal Fractures Metatarsal Fractures Common fractures Metatarsal Fractures Most heal without issue but there are a few exceptions l Jones Fractures Mechanism l Often a turning or twisting injury to the foot/ankle l Crush injury 10

11 Physical Exam Metatarsal Fractures l Usually swelling around fracture site and often into entire foot and/or ankle l Ecchymosis doesn t always stay confined to fracture site Often see on plantar aspect of foot, into toes and on medial and lateral sides of the foot l May have limp, may or may not be able to weight bear Xrays Metatarsal Fractures l Always get three views of the foot AP, Lateral and Oblique Metatarsal Fractures 5 th Metatarsal Shaft Fractures Oblique, AP and Lateral (from left to right) 5 th Metatarsal Shaft Fractures 5 th Metatarsal Shaft Fractures Symptomatic Treatment l Almost all go on to heal l Hard soled shoe (ok to come off for showers/ sleeping) l Crutches but WBAT l Rest, ice, elevation l May need opiates early on, can then switch to Tylenol Avoid NSAIDS l Typically see clinical union around 6 weeks 11

12 5 th Metatarsal Shaft Fractures 5 th Metatarsal Shaft Fractures Xrays will take a long time to look healed No referral necessary if you are comfortable managing If you prefer ortho to see, patient should be seen within a week or two of the injury Jones Fracture of 5 th MT Jones Fracture of the 5 th MT This is one you do not want to miss Jones Fracture of 5 th MT High rate of nonunion (up to 30%) Treatment is typically 8+ weeks, non weight bearing in a cast l As a rule here, our traumatologists don t treat surgically unless there is a nonunion Foot/Ankle and Sports surgeons tend to be quicker to operate l May be reasonable especially in athletes or those with other foot deformities (club foot, high arches) Jones Fracture of the 5 th MT If comfortable following and you have casting, follow previous plan If not comfortable following: l Make patient non weight bearing with crutches Ok to use a splint or a boot for initial treatment if casts are not available (so long as patient is NWB) l Opiates are sometimes necessary for the first few days Avoid NSAIDS l Get to Ortho within a week for evaluation 12

13 Avulsion Fractures of the 5 th MT Avulsion Fracture of the 5 th MT Mechanism l Sudden inversion injury puts strain on attachment of peroneus brevis to proximal 5 th MT l Avulsion fracture results Exam Avulsion Fractures of 5 th MT l Again, swelling and tenderness about fractures site l May have ecchymosis outside of the fracture site Plantar aspect of foot, toes Avulsion Fractures of 5 th MT Treatment l Because this injury essentially crosses the ankle joint, you must immobilize the ankle as well as the injured foot l Boot (ok to come off for showering and sleep) l Usually there is no need for opiates, Tylenol is appropriate l WBAT l Most patients do very well within 6 weeks Boot Avulsion vs. Jones Jones Fracture Avulsion fracture 13

14 Almost there! Toe Fractures Common and almost always do well with symptomatic treatment l Buddy tape l Hard soled shoe l Tylenol for pain (no NSAIDS) l WBAT l F/U only if pain persists beyond 6-8weeks Ortho referral probably not necessary Toe Fractures Toe Fractures Toe Fractures Toe Fracture Buddy Taping 14

15 Hard Soled Shoe Toe Fractures If you have a significantly displaced great toe fracture that enters the joint, have them see ortho. Uncommon! Follow Up Emergency consults l Open fractures, suspected compartment syndrome Urgent Consults l Displaced fractures, dislocations/subluxations When in doubt, call Ortho! A few more pearls When ordering xrays, always make sure you have 2 views at 90 angles to one another (exception: clavicle) If you can t see what you need to see, send them back for more l Never accept sub par films Always make sure you get films of the joints above and below a long bone injury More Pearls Questions? Remember you won t see radiographic evidence of bone healing in adults for about 4-6 weeks. Try to avoid NSAIDS with fractures Smoking, Diabetes, and infection also impact bone healing Intraarticular fractures should probably see Ortho (exception: toes) 15