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Fracture Management

for Primary Care


Physicians
Thomas
Berkbigler, DO, PT
Orthopedic Surgeon

Disclosures
None that I am aware of that will bias this
talk

Why are we discussing this?


Orthopedic problems are over 10% of all
primary care visits
1.6% of all visits to any physician are
fracture related
16% of all fracture care is handled by
family physicians

Objectives
1.
2.
3.
4.
5.
6.
7.
8.

Identify common fractures in Primary Care


Proper use of a splint versus a cast
Identify commonly used casting materials and when to
use them
Demonstrate proper cast application and removal
Describe appropriate patient education with regards to
casting
Understand general fracture principles, when to refer
out fracture care
Understand management of specific fractures
Recognize osteoporotic fractures

General Principles
Two (2) Principle Questions
1. What to Refer?
How to stabilize

2. What to Manage on my own?


How to treat what I keep

Casting - Overview
Mainstay of treatment for most fractures
Joint above and a joint below
Avoid pressure points

Proper molding
Cast indentations

Appropriate padding

More at bony prominence


Not too much at fracture site

Consider skin wounds

Splinting - Overview
Purpose
Reduce pain
Reduce bleeding and swelling
Prevent further soft tissue damage
Prevent vascular constriction

What to splint
Fracture
Dislocation
Tendon rupture

Supplies
Stockinette
Padding material
Cast material

Plaster: cheaper, long shelf life, easier to


work with
May be fragile, disintegrate in water

Fiberglass: more durable, lighter, dry quicker,


multiple colors, water tolerant
Newer synthetic materials

Procedure
Apply stockinette

Protect skin and provide smooth edge

Apply padding

Protect bony prominence


Allows for swelling

Wet the casting material

Hot water hardens faster


Squeeze out excess water

Apply splint or cast

Patient Instructions
Keep injured limb elevated and iced
Warning signs

Numb extremity - Inability to move extremity


Discoloration, Cold
- Increased pain

Avoid getting wet

Completely with plaster


May use hair dryer on cool setting if fiberglass

Anti-histamines

Splint Types
Upper Extremity:

Wrist Cock-up
Ulnar Gutter
Long arm Splint

-Sugar-tong
-Radial Gutter
-Coaptation

Lower Extremity:

Posterior Ankle slab


Long leg splint

-Stir-ups

Take Home Points


You will see fractures
Know your comfort level and when to refer
Splint acutely and with active swelling
Variety of materials

Know what you have, be comfortable with it

Educate your patients

Fractures

General Principles
Two (2) Principle Questions
1. What to Refer?
1. How to stabilize

2. What to Manage on my own?


How to treat what I keep

OLD ACIDS
Mnemonic
O: open or closed
L: location
D: degree
A: articular involvement
C: comminution/type
I: instrinsic bone quality
D: displacement
S: soft tissue injury

Metatarsal / Phalanges
Keep
1.
2.
3.

Minimally/Non-displaced fractures
Short leg cast
NWB 4-8 weeks

Refer
1.
2.

3.
4.

Lis Franc fracture or Jones Fracture


Displaced Metatarsal Shaft or intra-articular
fractures
Multiple fractures
Short leg splint; NWB

Ankle Fractures
Keep:

Avulsion fractures and some Weber A type


Some Weber B fractures
Need stress radiograph

Splint : posterior slab +/- stirrups x1 week


Cast: Short leg x2-6 weeks
NWB 2-8 weeks
AROM ~4 weeks
PT for ankle strengthening and proprioceptive training

Ankle Fractures
Refer:

Bi/Trimalleolar Fractures
Bimalleolar Equivalency Fractures
Talar subluxation
Articular impaction
Syndesmosis dysruption
Treatment: Reduce and Splint (Posterior slab with
stirrups)
Significant Joint involvement Obtain post-reduction
CT

Clavicle Fractures
Keep

Shaft type with minimal displacement and


shortening
Sling or Figure 8 for 4-6 weeks
ROM/Strengthening thereafter

Refer

Comminution, shortening, distal/proximal type


Sling

Proximal Humerus Fracture


Neer Classification

1.
2.
3.
4.

Helps determine
treatment

1-Part
2-Part
3-Part
4-Part

Proximal Humerus
Majority need close follow up with
Orthopedics
Even if non-displaced initially may
displace later or present with later stage
rotator cuff issues.
Sling or Sling and Swathe
Osteoporotic Fracture

Distal Radius
Most common orthopaedic injury with a
bimodal distribution

younger patients - high energy


Elderly patients low energy fall (OP)

Manage?

Non-displaced extra-articular
Well reduced extra-articular with good bone
quality in a well-molded cast/splint

Distal Radius Fractures


Barton's

A depressed fracture of the


lunate fossa of the articular
surface of the distal radius
Fx dislocation of radiocarpal
joint with intra-articular fx
involving the volar or dorsal lip
(volar Barton or dorsal Barton)

Chauffer's

Radial styloid fx

Die-punch

Colles'
Smith's

Low energy, dorsally


displaced, extra-articular
Low energy, volar displaced,
extra-articular fx

Take home pointunderstand the


energy

Surgical Options

How to treat?
Options:

Splint and refer?


Splint and cast later?
Reduce and splint?
Cast and manage?
Reduce and Cast?

Scaphoid Fractures
Scaphoid is most frequently fractured carpal
bone; 15% of wrist injuries
Prognosis

incidence of AVN with fracture location


Proximal 1/5 = 100%

Proximal 1/3 = 33%

Wrist pain after fall

Splint vs. Cast 2 weeks


Repeat xrays no fx, continued snuff box pain and
pain with pronation = MRI

Refer out thumb spica splint or cast

Oops
If texting an
imageplease
include the
whole xray

Osteoporosis
By Definition: Fall from standing resulting
in Proximal Humerus, Distal Radius, Hip
fracture, Spine compression fracture
CBC, CMP, T4, TSH, Vit D3 level
Bisphosphonate?
Forteo?

Drug class: Parathyroid Hormone Analog

Question #1: In General, when should a splint be


applied to a fracture, in lieu of a cast?

1.
2.
3.
4.
5.

In the acute presentation


Highly swollen extremity
Compromised Skin
None of the above
All of the above

#1 Answer
5. All of the above

Question #2:

1.
2.
3.
4.
5.
6.

Which Fracture when obtained in an adult from


a simple fall does not meet criteria for
Osteoporosis?
Femoral Neck Fracture
Scaphoid Fracture
Hip Intertrochanteric Fracture
L2 Compression Fracture
Distal Radius Colles Fracture
Comminuted 4-Part Proximal Humerus
Fracture

#2 Answer
2. Scaphoid

Question #3:

1.
2.
3.
4.
5.

Which Metatarsal Fracture is easily


treated by a Primary Care Physician?
Jones Fracture
Fifth (5th) Metatarsal Avulsion fx
Lis Franc Fracture
Marching Fractures
Widening of the 1st Inter-metatarsal web
space

#3 Answer
2. Fifth (5th) Metatarsal Avulsion fx

Question #4:

1.
2.
3.
4.
5.

What are some complications with


elderly distal radius Colles fractures?
Continued fracture collapse
Carpal Tunnel Syndrome
Skin Tears from fall or from reduction
Loss of ROM
Profound dexterity achievement after
cast immobilization

#4 Answer
4. Profound dexterity achievement after cast
immobilization
i.e. If you had poor piano skills
before

Question #5:
Which Clavicle is a good candidate for
non-operative management?
A
B
C
D

B
C

#5 Answer
C

References
Eiff MP, et al. Fracture management for Primary
Care, 2nd edition. Saunders. 2003.
Honsik K, et al. Sideline splinting, bracing and
casting of extremity injuries. Current sports
Medicine Reports. 2003;2:147-154.
Meredith RM, et al. Field splinting of suspected
fractures: preparation, assessment, and
application. The Phys and Sports Med.
1997;25(10).

Calcaneus and Talus


Keep

None
Short leg splint; NWB
Complicated High long-term pain rate
Typically Higher energy fractures

Tibia Shaft Fractures


Keep

Very few
Most - Long leg splint and refer

Minimal allowance for mal-alignment: trend is


to stabilize surgically for early ROM
Exceptions:
Toddlers Fracture

Obtain phone consult of Orthopedist

Elderly/Non-ambulatory minimally displaced

Well padded Long leg cast

Femur Shaft Fractures


Non-operative: only in the baseline nonambulatory or severely unhealthy

Non-displaced: NWB 8-12 weeks


Displaced: NWB essentially lifelong

Operative:

ORIF via Plate and screw construct versus IM


Nail

Hip Fractures Femoral Neck


Non-operative: only in the baseline nonambulatory or severely unhealthy

Non-displaced: NWB 8-12 weeks


Displaced: NWB essentially lifelong

Operative:

Closed reduction and perc screws; Hemi


versus Total Hip Arthroplasty

Hip Fracture - Intertrochanteric


Non-operative: only in the baseline nonambulatory or severely unhealthy

Non-displaced: NWB 8-12 weeks


Displaced: NWB essentially lifelong

Operative:

Intramedullary Nail Device versus DHS type


device

Humeral Shaft Fracture


Complex Fractures

Acceptable limits: <30 Anterior; <20 Var/val;


<3cm shortening
Associated with radial nerve palsy

Refer most out

Coaptation splint +/- long arm splint

Definitive treatment: varied, Hanging arm


cast, Sarmiento, ORIF, IM Nail

Fractures About the Elbow


Refer: Supracondylar, Intercondylar, Olecranon,
intra-articular, displaced, elbow dislocation

If elbow dislocation, reduce, long arm splint

Radial Head/Neck Fx

isolated minimally displaced (less than 2mm) fxs with


no mechanical blocks
Long arm splint x3-7 days, then early ROM
Consider aspiration

Mason Classification
Type I Minimally displaced fx,
no mechanical block to
rotation, intra-articular
displacement <2mm
Type II Displaced fx >2mm or
angulated, possible
mechanical block to forearm
rotation
Type III Comminuted and
displaced fx, mechanical block
to motion
Type IV (Hotchkiss
modification)Radial head fx
with elbow dislocation