Common Fracture Management

1. Common Fracture Management Brandon Mines, MD March 24th, 2011

2. Terminology • Open fracture • Closed fracture • Displacement • Angulation • Comminution Open

3. Distal Radius Fracture • Fall on outstretched hand (FOOSH) • Immediate pain or delayed • Skateboarders • Snowboarders • I just plain fell!

4. Distal Radius Fracture:Exam • Swelling • Deformity • Bruising • TTP • Neurovascular status

5. Distal Radius Fracture:Acute Management • Remove rings! • Assess plain films • AP & lateral • Extra-articular more common • Intra-articular • Usually does fine with casting

9. Distal Radius Fracture:Acute Management • How much displacement? • Dorsal displacement/angulation • Get it back to neutral • Volar displacement • Usually need ORIF

10. Distal Radius Fracture:Acute Management • Reduction • Hematoma block • Finger traps/elbow grease • Surgical consult • Volar displacement • Reduction not holding

12. Distal Radius Fracture:Acute Management • Sugar tong splint • Neutral wrist (can-hold position) • 3-7 days to allow for swelling

13. Distal Radius Fracture:Acute Management • After 3-7 days, apply short arm cast • Neutral wrist again • Sports and activities ok with cast • May need proper padding or gortex liner

14. Distal Radius Fracture:Management • At ~ 4 weeks from injury • Remove cast • AP & lateral x-rays • May see some callous • Weekly x-rays if reduction was done

15. Distal Radius Fracture:Management • Most need another cast • 2 weeks or so • At that point, should see callous • Less pain or pain free • Will be stiff! • OT, home exercises • Longer time frame for low BMD

16. Lateral Malleolus Fracture • Inversion • Fall • High energy • Sports • MVA

17. Lateral Malleolus Fracture • Swelling • Deformity • Bruising • TTP • Neurovascular status • Antalgic gait

18. Lateral Malleolus Fracture • Assess for other injuries • 5th Metatarsal • Achilles • Medial malleolus

19. AP Lateral Oblique

20. Lateral Malleolus Fracture:Diagnosis • Isolated malleolar fractures are usually stable • Get ortho involved if: • Bi-malleolar fracture • If fracture is very proximal to joint

21. Lateral Malleolus Fracture:Acute Management • Posterior splint for 3-7 days • Ankle at 90° • Non-weightbearing (NWB) • Elevate

22. Lateral Malleolus Fracture:Management • After splinting, cast or long boot for 3 weeks • NWB • Cast and boot equally hold fracture stable • Wear boot like a cast, but keep it dry inside! • Compliance issues with boot • Boot allows for better transition to walking

23. Lateral Malleolus Fracture:Management • Now at ~ 4 weeks into injury • AP, lateral, oblique out of cast • +/- callous • Check for fracture pain • If trace/no TTP at fracture with callous, can start WB • If TTP and minimal callous, keep NWB 1-2 wks

24. Lateral Malleolus Fracture:Management • Need to get 1-2 weeks of WB in boot prior to stopping it • Total time in boot/cast ~ 6-8 weeks • Low BMD may be longer • Stiff • PT • HEP

26. Clavicle Fracture • Most occur in middle one-third of clavicle • Fall on outstretched arm or point of shoulder

27. Clavicle Fracture

28. Lateral clavicle fractures are tricky to heal • lots of “tug” from ligaments • consider referral for that one

30. Clavicle Fracture:Exam • Visible & palpable deformity • Local pain & swelling • Pain may radiate

31. Clavicle Fracture:Exam • Rare to have rotator cuff tears • They will look like cuff tear patients initially • Listen to lungs if significantly displaced to r/o pneumothorax • Complete neuro exam important to detect brachial plexus injury

32. Clavicle Fracture:Diagnosis • Radiographs: • AP view • AP view w/ 45° cephalic tilt • (Chest film if substantial trauma)

33. Clavicle Fracture:Management • Ortho referral for: • Skin tenting • Severe displacement • Severe comminution • Conservative for most • It can look scary, but most do fine

34. Sling for 2 to 4 weeks, as needed • Figure 8 no better than sling

35. Clavicle Fracture:Management • ROM as pain allows is fine • Recheck with x-rays in 3 weeks • Some motion has returned now • 50-75% at 4 – 5 weeks • A bit sore, but TONS better

36. Clavicle Fracture:Management • Can do some pendulum exercises as tolerated • Most feel able to at 2-4 weeks • Consider starting some gentle PT at about 5 week mark

37. Clavicle Fracture:Management • Good news… • If it doesn’t heal, all you lost was time • ORIF is still effective later

38. The most frequently injured carpal bone Only distal radius fractures are more common in the wrist Most commonly seen in young men Rarely seen in children (distal radial physis is weaker) Scaphoid fractures

39. Scaphoid fracture • Increased incidence of nonunion and osteonecrosis • Blood supply enters distally in bone • The more proximal the fracture, the more the risk of non-union

40. Fall on outstretched hand May not be severe pain May continue to use the wrist Dull, deep discomfort on thumb side of wrist Scaphoid fracture

41. Scaphoid fracture: Palpation • Anatomic snuffbox • Tendons bordering it more prominent when thumb extended

42. Scaphoid fracture: Scaphoid palpation • Be sure to try some ulnar deviation to palpate the scaphoid • Can be sensitive area, so palpate other side also for comparison

43. Also try to palpate the scaphoid turbercle Scaphoid fracture: Scaphoid palpation

44. May see decreased motion and grip strength Don’t forget neurovascular status Tender with scaphoid palpation Scaphoid Fracture:Exam

45. Scaphoid fracture

47. Scaphoid Fracture:Acute Management • Remember, if unsure of fracture, treat it like it is broken • Thumb spica splint • Recheck in 7 - 10 days

48. Thumb spica cast May be in cast for 3-4 months, and still not heal Referral to hand surgeon Get opinion on ORIF Any type of displacement Athletes Proximal pole fractures ScaphoidFracture:Management

49. 5th Metatarsal Fracture • Inversion • Fall • May seem minor

50. 5th Metatarsal Fracture • Swollen • Bruised • +/-Limited motion • Antalgic gait