Final Basic Fracture Overview for IPAS Fall CME 2014

11/5/14

I will try to make this painless Great, a Fracture, Now What?

Mary Greve MS, PA-C Department of Orthopedic Surgery Trauma Team University of Iowa Hospitals and Clinics [email protected] Pager 2121

Objectives Basics for Fracture Workup

¡ Lots of learners in clinic have the same ¡ History

concerns and questions l Mechanism of injury? l How do I describe fractures competently? ¡ Tells you what to look for l What can I take care of? l Timing of injury? l What needs to be referred? ¡ New or old, has the patient been weight bearing etc.

l Urgency ¡ We will cover some of the most common fractures that can be managed by PCPs

Basics for Fracture Workup Basics of Fracture Workup

¡ Physical Exam ¡ X-rays l Always get at least 2 views of the injured area (at 90 deg l Inspection is much of exam angles to one another) ¡ Ecchymosis, swelling, skin exam, deformity, open fracture ¡ If you are unsure which films to get, call ortho or radiology l Neurovascular Checks ¡ X-rays of joint above and below injury if injury is to a long bone (ex: forearm fractures need elbow and l Exam of joints above and below wrist films)

l Ok to ask for active range of motion but passive range of motion should not be done until x-rays are done

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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 Other things to communicate

¡ When calling ortho, be able to tell us which films l Are there other injuries (head, chest, belly, limb)? you have and try your best to describe the fracture ¡ What is the condition of the patient? l Start with which bone is injured l Your limitations (film quality, lack of casting/ l Is it an open or closed injury? (compound is an old term) splinting etc.) 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?

How You Might be Feeling Now

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Here’s the Pattern Review of Terms

¡ What Xrays do you have? ¡ Review of bone anatomy (physis, metaphysis, diaphysis etc) ¡ Name of bone broken ¡ Junction of two ¡ 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 Terms

¡ Pattern/Orientation ¡ 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

Translation Review of Terms

¡ Angulation – where is apex pointing? ¡ What about this l Anterior? Posterior? Dorsal? Volar? Valgus? Varus? one? ¡ Translated about 75%

Valgus alignment ->

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Angulation Review of Terms ¡ Example of apex ¡ Rotation (just know anterior angulation it’s rotated!)

¡ 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? How would you describe this?

¡ AP view of the forearm which shows both the wrist and elbow (adequate films) ¡ Lateral view confirms ¡ There are fractures of both what you’ve seen on the radius and ulna at the the AP junction of the distal 1/3 and middle shaft ¡ Not a perfect lateral ¡ Oblique l In this case, don’t ¡ Not comminuted torture the patient with another attempt ¡ Translated 100% ¡ Maybe rotated? ¡ Shortened a bit ¡ What else???

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Lets Try Another One Lets Try Another One

¡ AP view of humerus ¡ Lateral view that does ¡ Includes shoulder and elbow not include shoulder joints (good quality) ¡ Midshaft humerus ¡ Midshaft humerus fracture fracture, transverse, l Transverse simple (as before) l Simple (not comminuted) l Translated 25-50% ¡ Apex anterior l No rotation angulation (25-30 deg) l No shortening

Do you feel like this kid?

¡ On to the fractures….

Clavicle Fractures Clavicle 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)

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Clavicle Fractures Clavicle Fractures

¡ 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 Clavicle Fractures

¡ Xrays l AP Clavicle view l It’s reasonable to get a full shoulder series to rule out other injuries as well AP clavicle ¡ AP, Grashey (true AP), Axillary (lateral view of shoulder) AP shoulder

Grashey Axillary

Clavicle Fractures Midshaft Clavicle Fractures

¡ Fracture location l 85% are midshaft l 10% are in the distal 1/3 l 5% are in the proximal 1/3

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Figure of Eight Brace (patients won’t Midshaft Clavicle Fractures like you but they’ll think you’re smart!) 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

Clavicle Fractures Clavicle Fractures

¡ 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 Distal Clavicle Fracture ¡ 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)

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Distal Clavicle Fractures Questions so far?

¡ If nondisplaced, simple treatment with sling ¡ If very displaced, the nonunion rate can be high - refer

Radial Head Fractures

Isolated Radial Head Fractures Isolated Radial Head Fracture

¡ Physical Exam ¡ Make up about 20% of all elbow injuries l Sore, painful elbow l Most common elbow fracture in adults l May or may not be ecchymotic l Usually can’t see much swelling in an elbow on exam ¡ Mechanism l Painful movement l Fall onto an outstretched hand ¡ Especially pronation/supination

¡ Almost never able to extend completely l Pain over radial head on palpation

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Isolated Radial Head Fractures Isolated Radial Head Fractures

¡ Xrays l AP, Lateral and Radial Head views ¡ Always consider radial head views on x-ray exam of any elbow

¡ 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 Isolated Radial Head

¡ Treatment ¡ When to see ortho? l Sling for 2-3 days for comfort only l If you are comfortable treating non displaced l After 2-3 days, the sling should come off for fractures, no referral is necessary range of motion (flex, ext, supination, pronation) l If the fracture is displaced, or you are uncomfortable, refer within the first 3-4 days ¡ Don’t let elbows get stiff!! ¡ Ortho will reinforce early range of motion and ¡ If still stiff at 2-3 weeks, consider PT removal of sling. l Low level opiate for a week or two ¡ This is not emergent so it’s ok to wait longer to see ¡ Tylenol is ok, NSAIDS should be avoided ortho if necessary. l Return to activities as tolerated ¡ GET THEM MOVING!

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Pearls Doing ok?

¡ Fractures may not show up at the time of injury but will likely be more apparent 10-14 days later l Consider repeat films in someone with clinical suspicion of fracture with no x-ray evidence

Metatarsal Fractures

¡ Common 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

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Metatarsal Fractures Metatarsal Fractures

¡ Physical Exam ¡ Xrays l Usually swelling around fracture site and often l Always get three views of the foot

into entire foot and/or ankle ¡ AP, Lateral and Oblique 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

Metatarsal Fractures 5th Metatarsal Shaft Fractures

¡ Oblique, AP and Lateral (from left to right)

5th Metatarsal Shaft Fractures 5th 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

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5th Metatarsal Shaft Fractures 5th 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 5th MT Jones Fracture of the 5th MT

¡ This is one you do not want to miss

Jones Fracture of 5th MT Jones Fracture of the 5th MT

¡ High rate of nonunion (up to 30%) ¡ If comfortable following and you have ¡ Treatment is typically 8+ weeks, non weight casting, follow previous plan bearing in a cast ¡ If not comfortable following: l As a rule here, our traumatologists don’t treat l Make patient non weight bearing with crutches

surgically unless there is a nonunion ¡ Ok to use a splint or a boot for initial treatment if ¡ Foot/Ankle and Sports surgeons tend to be quicker to casts are not available (so long as patient is NWB) operate l Opiates are sometimes necessary for the first few l May be reasonable especially in athletes or those with days other foot deformities (club foot, high arches) ¡ Avoid NSAIDS l Get to Ortho within a week for evaluation

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Avulsion Fractures of the 5th MT Avulsion Fracture of the 5th MT

¡ Mechanism l Sudden inversion injury puts strain on attachment of peroneus brevis to proximal 5th MT l Avulsion fracture results

Avulsion Fractures of 5th MT Avulsion Fractures of 5th MT

¡ Exam ¡ Treatment l Again, swelling and l Because this injury essentially crosses the ankle tenderness about fractures site joint, you must immobilize the ankle as well as the injured foot l May have ecchymosis outside of the fracture l Boot (ok to come off for showering and sleep) site l Usually there is no need for opiates, Tylenol is ¡ Plantar aspect of foot, appropriate toes l WBAT l Most patients do very well within 6 weeks

Boot Avulsion vs. Jones

Jones Fracture

Avulsion fracture

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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

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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 A few more pearls

¡ Emergency consults ¡ When ordering xrays, always make sure you l Open fractures, suspected compartment syndrome have 2 views at 90 angles to one another (exception: clavicle) ¡ Urgent Consults ¡ If you can’t see what you need to see, send l Displaced fractures, dislocations/subluxations them back for more l Never accept sub par films

¡ When in doubt, call Ortho! ¡ Always make sure you get films of the joints above and below a long bone injury