SNAP, CRACKLE, POP Randy L Aldret, EdD, ATC, LAT Stephanie Aldret, DO, CAQSM OOA Winter CME Seminar January 26, 2018 1
OBJECTIVES Review terms to describe fractures Identify fractures that can be treated in the primary care office Review the important history and patient symptoms for various fractures Describe the physical exam findings and diagnostic tests for various fractures Describe the common management of the discussed disorders ON-FIELD/SIDELINE MANAGEMENT 2
INITIAL ASSESSMENT Circulation, Airway, Breathing Neurovascular function Motor function and Sensory Pulses, Color, Temperature, and Turgor Examine for tenderness and range of motion Perform a complete examination for other injuries LOC Spine Systemic injuries High index of suspicion based on mechanism of injury Immobilize while waiting for X-ray Provide analgesia Immediate fracture reduction if neurovascular compromise, severe displacement or skin tenting TYPES OF FRACTURES Traumatic Stress/Fatigue Pathologic 3
FRACTURE BASICS Anatomic Location Fracture Patterns Alignment Soft Tissue Status Neurovascular Status Associated Injuries ANATOMIC DESCRIPTION OF FRACTURES Location Usually use a descriptor, then document the location on the bone Examples are: distal radial shaft proximal 1/3 humeral shaft intra-articular distal tibia Note describe proximal/distal, intra-articular/extra-articular first, then bone part involved 4
ANATOMIC DESCRIPTION OF FRACTURES Type Overall fracture pattern Examples Spiral Segmental Transverse TYPES OF FRACTURES The severity of a fracture usually depends on the amount of force that caused the break. There are many types of fractures including: Nondisplaced fracture Typically stable Displaced fracture Often requires surgery to put the pieces back together Reduction = manipulation of fracture to restore anatomy Open fracture Broken bones that break through the skin are called open, or compound and involve much more damage to the surrounding muscles, tendons, and ligaments Open fractures have a higher risk for complications and take a longer time to heal Closed fracture Although the skin is not broken, internal soft tissues can still be badly damaged Comminuted fracture Unstable The bone shatters into three or more pieces AAOS, Patient Information 5
ANATOMIC DESCRIPTION OF FRACTURES Displacement The position where pieces of a fracture have moved from their normal location Fractures can be displaced or non-displaced Displacement is subdivided into 3 sub-categories: Translation Angulation Shortening Translation Angulation Shortening 6
ANATOMIC DESCRIPTION OF FRACTURES Comminution The measure of the number of pieces of broken bone Often times this is a subjective assessment. Examples are: non-comminuted, mildly comminuted or severely comminuted Noncomminuted (Simple) Mildly comminuted ( Butterfly fragment ) Severely Comminuted AVULSION FRACTURES An avulsion fracture occurs when an injury causes a ligament or tendon to tear off (avulse) bone to which it is attached These type of fracture can occur throughout the skeleton The layman calls these chip fractures 7
SALTER-HARRIS CLASSIFICATION Only used for pediatric fractures that involve the growth plate (physis) Five types (I-V) SH Type II fracture, middle phalanx, right ring finger SH Type I fracture of the distal radius Displaced, SH Type II fracture, distal tibia SH Type IV fracture, distal tibia SH Type III fracture distal tibia 8
Usually a result of high energy trauma Open vs Closed SOFT TISSUE STATUS Graded by amount of soft tissue damage, energy of trauma and contamination Grade 1: wound < 1 cm, low energy and contamination Grade 2: wound 1 > 10cm, moderate energy and contamination Grade 3: wound > 10cm, high energy and gross contamination Swelling A: adequate coverage B: inadequate coverage, C: circulation impaired BLOOD SUPPLY TO BONE 9
ANATOMIC DESCRIPTION OF FRACTURES Describe each of the following in your report: Type Comminution Location Displacement / Translation / Shortening TREATMENT Immobilization of fracture Cast, splint or brace Traction External fixation Intramedullary nails, pins, k-wires Plate and screws, tension band wires Lag screw S T A B I L I T Y 10
TREATMENT In general: intra-articular fractures require anatomic reduction and rigid fixation Shaft fractures require less anatomic alignment and less rigid fixation Exception: radial shaft fractures General Concepts General Indications for Surgery: 1. Open fractures 2. Unstable fractures 3. Irreducible fractures 4. Multiple fractures 5. Fractures with bone loss 6. Fractures with tendon involvement Unstable Stable 11
CAST, SPLINT, CAST BRACE Advantages Non invasive Inexpensive Relatively easy to apply Disadvantages Lead to stiffness and muscle atrophy Not rigid, can not hold length Skin breakdown 12
First, do no harm. CASTING Most extremity injuries and stable fractures are immobilized in a position of function. Make sure that the skin is both clean and dry prior to the application of the cast or splint. No joint should be immobilized unnecessarily. When estimating the length of stockinette necessary for a short-arm or short-leg cast, make sure to allow extra so that it can be folded back and incorporated into the cast to create a finished edge. When applying cast padding, be sure to adequately pad bony prominences. Consider using materials that will allow the patient to get the cast wet. To facilitate application of the fiberglass casting tape, it should be rolled on with the roll positioned up (as if you were unrolling a rug). Apply it in a spiral fashion to the extremity, overlapping approximately 50 percent. Keep in mind that the curing time for most fiberglass products is 2-4 minutes, depending upon the brand name, type of product, and technique. Cast or splint molding should be performed until material is set, approximately 3 minutes after activated in water. Simple treatment with a cast and discharge before following the patient through a well-guided rehabilitation program is incomplete treatment. All dislocations must be reduced as soon as possible. Closed fractures do not constitute an emergency, unless there is evidence of neurovascular injury or impending skin breakdown. It is vital to give patients both verbal and take-home instructions concerning cast care. CASTING AFTER CARE INSTRUCTIONS Always make sure you have discussed proper cast/splint care with the patient and family, if appropriate. Document that you have done this. Items to cover include, but are not limited to, the following: Elevation of the injured extremity to help reduce swelling. Signs that the cast/splint is too tight include progressive pain, numbness/tingling, coldness, difficulty moving neighboring joints, and color changes in the extremity (pale or blue). Keep the cast/splint dry (unless special materials have been used). If a plaster cast/splint becomes wet, it needs to be replaced. If a fiberglass cast/splint becomes wet, the patient may try using a blow drier on a low heat setting. Do not put anything under the cast, as this could create pressure points, resulting in skin breakdown. Encourage patients to move nonimmobilized joints to enhance fluid return and decrease swelling. Allow adequate time for the cast/splint to harden before stressing it. 13
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EXTERNAL FIXATION Advantages Allows access to soft tissue Can maintain length Disadvantages Invasive Not very rigid Indirect reduction Pin tract infections INTRAMEDULLARY NAIL Advantages Do not disrupt periosteal blood supply Can maintain length Allow for early ROM Disadvantages Invasive Indirect reduction 15
PLATE AND SCREWS, LAG SCREW Advantages: Most rigid Allows for direct reduction > Anatomic alignment Allows for early ROM Disadvantages Strips blood supply to bone Nondisplaced, transverse fracture of the scaphoid 16
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SUMMARY Fracture management dictated by: Location Fracture pattern Soft tissue status Patient Factors (age, associated injuries) Fixation is a balance between rigidity and violation of the soft tissues Remember what to include in the description of fractures Type Comminution Location Displacement/Translation/Shortening Simple, transverse, non-communited midshaft radial and ulnar fractures with 30 degrees apex radial angulation. 18
Transverse, midshaft fractures of radius and ulna with complete displacement, shortening and ulnar angulation of the radial fracture Displaced, transverse, radial shaft fracture at the junction of the mid and distal thirds with accompanying subluxation of the distal radio-ulnar joint(druj). Management: in adults, requires surgical open reduction of the distal radius and DRUJ with internal fixation. In children the fracture can often be treated by closed reduction. 19
Greenstick fracture Incomplete, one cortex is not fractured (may be bowed or bent, but not fractured). Nondisplaced, 2 bone forearm shaft fractures at the junction prox. and mid. thirds in a growing skeleton. 20
Nondisplaced, transverse fracture of the ulna at the junction of the proximal and middle shaft. Night-stick fracture Treatment: Nondisplaced cast May require ORIF if displacement occurs Transverse, dorsally angulated, extraarticular fracture of the distal radius with an associated ulnar styloid fracture (Colle s Fracture) When describing fracture angulation and displacement with regards to the distal radius, describe the position of the distal fracture fragment with respect to the proximal fracture pattern. 21
Oblique, volarly displaced, extraarticular fracture of the distal radius (Smith s Fracture) Comminuted Volar Barton s fracture Barton s Fracture Barton s fracture is an intra-articular fracture of distal end of radius bone. Displacement can be dorsal or volar. 22
Nondisplaced radial styloid fracture AKA Hutchinson s fracture, Chauffeur s fracture, Backfire fracture The injury is typically caused by compression of the scaphoid bone of the hand against the styloid process of the distal radius. It can be caused by falling onto an outstretched hand. Treatment -often ORIF which is surgical realignment of the bone fragments and fixation with pins, screws, or plates. Torus or buckle fracture Here the cortex is buckled rather than fractured through as seen in greenstick fractures. Commonly used in pediatric fractures, i.e., growing bones. 23
Transverse, nondisplaced, impacted fracture of distal radius Transverse, completely displaced midshaft fracture of the fourth metacarpal 24
Transverse, angulated, slightly displaced fractures of the 4 th and 5 th MCP shafts Metacarpal fractures: Because of the mobility of the MPJ s of the ulnar two digits, considerable residual angulation can be accepted w/o compromising hand function. Advise patients that their knuckle is gone forever. 25
Oblique, dorsally angulated fracture of the 5 th MCP shaft. Overlapping finger due to rotational malalignment of fracture metacarpal 26
Oblique, displaced, intra-articular fracture of the ulnar base of the 1 st MCP Comminuted, displaced, intra-articular fracture of the base of the 1 st MCP Bennett s Fracture Rolando s Fracture Minimally displaced, comminuted, intraarticular fracture of the distal end, proximal phalanx of the index finger. Nondisplaced oblique fracture of the shaft of the proximal phalanx of the small finger. 27
Mallet Fracture Splinting 24/7 for six weeks. Gamekeeper s Thumb aka Skiier s Thumb Stener lesion adductor aponeurosis prevents UCL to reposition 28
Mallet Fracture Splinting 24/7 for 6-8 weeks THUMB MCP ULNAR COLLATERAL LIGAMENT Tear of the UCL of thumb Gamekeeper s thumb Skier s thumb Hyperabduction of the thumb MCP joint Often after a FOOSH with thumb abducted A stable UCL is needed for effective pinch Stener lesion Occurs in complete tears Distal edge of the ligament held in a displaced position by the ADDuctor aponeurosis The ligament cannot heal in normal anatomical position and residual instability occurs Treatment Partial tears usually cast immobilization or functional bracing w/ MCP in slight flexion for 4-6 weeks Complete tears get referred for surgery 29
Fat pad sign When fat pad sign is seen, suspect fracture of radial head. This sign represents bleeding in the joint, hemarthrosis. Oblique, nondisplaced fx. of the junction of the mid and distal thirds of the left clavicle 30
Oblique, comminuted, displaced fx. of the femoral shaft with 6cm of over-riding Transverse, minimally displaced fracture of the distal femur at the diaphyseal/metaphyseal junction with approx. 45degrees anterior angulation. Markedly comminuted, displaced, intraarticular tibial plateau fracture Comminuted, nondisplaced, midshaft tibial fracture with a large butterfly fragment Comminuted, moderately displaced, left tibial pilon fracture with intraarticular extension and an associated proximal fibular fracture 31
Transverse, nondisplaced medial malleolar fracture with associated oblique, slightly displaced, distal fibular fracture Oblique, displaced lateral malleolar fracture with lateral subluxation of the tibiotalar joint and widening of the medial joint space Comminuted, nondisplaced calcaneal fx. 32
Oblique, minimally displaced fx of the fifth metatarsal shaft Minimally displaced avulsion fx. of the medial base and an nondisplaced, intraarticular fx. of the medial condyle of the proximal phalanx of the great toe. 33
FOREFOOT FRACTURES Jones Fracture Very commonly seen fracture SLC or rigid boot is excellent treatment in most cases Certain fractures respond well to screw fixation Phalanges FOREFOOT FRACTURES Tx.: Buddy-taping and comfortable shoe 34
ORTHOPEDIC EMERGENCIES Compartment Syndrome Dysvascular extremities Native hip dislocations Displaced femoral neck fractures in the young patient Knee Dislocations Open fractures Septic Arthritis COMPLICATIONS Malunion Functional and /or cosmetic deformity Nonunion Infection Delayed closure necessary at times Joint extension contracture Remember protected position Loss of motion Secondary to tendon adherence Posttraumatic arthritis Failure to restore articular congruity 35
REFERENCES Kenneth D Amato, DO 36