Common Fractures Surgery Versus Not
Luis E. Palacio, MD Sports Medicine Agenda
• Basic Principals • Pediatric Fractures • Referral Decisions • Upper Extremity • Lower Extremity
Sports Medicine Prevelance
Sports Medicine Healing
Sports Medicine Description
Sports Medicine Description (Type)
Sports Medicine Description (Displacement)
Sports Medicine Splinting and Casting
• Patients placed in a splint/cast require monitoring • Selection varies based area being treated, acuity and stability • Splints are non-circumferential, more forgiving, allow for swelling • Casts are circumferential • Superior immobilization • Less forgiving • Higher complication rates • Reserved for definitive fracture management
Sports Medicine Splint and Casting Complications
• Ischemia • Heat injury • Pressure sores and skin breakdown • Infection • Dermatitis • Neurologic injury and compartment syndrome • Excessive immobilization can lead to chronic pain, joint stiffness, muscle atrophy, or more severe complications, such as complex regional pain syndrome
Benjamin HJ, Mjannes JM, Hang BT. Getting a grasp on hand injuries in young athletes. Contemp Pediatr. 2008;25(3):49-63 Sports Medicine Weight-Bearing vs. Non-weightbearing
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Sports Medicine Compartment Syndrome
Sports Medicine Compartment Syndrome
• 4 y/o with left wrist fracture • FOOSH • Seen at urgent care • Sent to ED • Reduced following day • Casted, No surgery
Sports Medicine Compartment Syndrome
Sports Medicine Pediatric Fractures
Sports Medicine Limping Child
• Contusion, strain, or sprain • Thorough history • Trauma • Possibility of infection • Fever • Night sweats • Anorexia • Malignancy
Sports Medicine Case
Sports Medicine Case: 14 yr old fall off bike
• Seen at urgent care • Documented lateral malleolus tenderness • X-ray • Soft tissue swelling • “No fracture”, “Mortise appears intact” • Skeletal maturity not noted on official report • Proper management?
Sports Medicine Case: 14 yr old fall off bike
• Pt was sent home with ACE wrap • Growth plate tenderness = Salter I • Tall boot and close follow up • Often heal within 4 weeks
Sports Medicine Case
Sports Medicine Case: 3 yr old trampoline injury, can’t walk
• Brought to UC by parent • Imaging read as “normal” • Sent home to “f/u with PCP”
Sports Medicine Case: 3 yr old trampoline injury, can’t walk
• Immobilization?
Sports Medicine When to Consider Surgical Referral
Sports Medicine Open Fractures
• High risk for osteomyelitis • Can be subtle
Sports Medicine Skin Tenting
Sports Medicine Vascular Damage
Sports Medicine Multiple Bones
Sports Medicine Articular Involvement
• Step-off deformity • Articular
Sports Medicine Upper Extremity
Sports Medicine Humerus
Most are non-operative
About 2/3 are non-operative Younger patients operative
Most are operative 50% Unless non-displaced Type A
Sports Medicine Forearm Most are operative Non-operative if small avulsion Most are non-operative or non-displaced Early ROM
Most are non-operative Most are operative If Isolated ulna and non-displaced or minimally displaced
Many are non-operative Serial X-rays to verify alignment
Radius and Ulna Sports Medicine Radius
Sports Medicine Radial Head
• Non-displaced < 2mm • Pronation/Supination • Immobilize 2-3 days and early ROM
Sports Medicine Radial Head (Surgical Consult)
• Block to motion • > 2 mm displacement • Concomitant injuries • Retained loose bodies
Sports Medicine Case
Sports Medicine Distal Radius Fracture (PEDS)
• Torus Buckle • Splint 3 weeks • Gradual return to activities when motion and strength return
Sports Medicine Distal Radius Fracture (PEDS)
• Non-displaced • Minimally displaced • Short arm cast for 6 weeks • Serial X-rays
Sports Medicine Case
Sports Medicine Distal Radius Fracture (PEDS)
• Displaced • Closed Reduction • Short arm cast for 6 weeks • Serial X-rays • Intra-articular (CT/MRI)
Sports Medicine Distal Radius Fracture (Adult)
• Nondisplaced • Cast/Splint • Re-X-ray in 1 week • If continued non-displacement • Cast total 4 weeks
Sports Medicine Scaphoid Fracture
• 70% of all carpal injuries • Principal block to wrist extension • Middle to proximal Fractures are prone to non-union Circulation Comes • Nondisplaced 95% healing in Distal pediatric patients to Proximal
Sports Medicine Scaphoid Fracture
• Almost all non-displaced scaphoid fractures thumb spica cast • Repeat x-rays in 7-10 days then monthly to assess union • 8 – 10 weeks of immobilization
Sports Medicine Scaphoid Fracture (Surgical Consult)
• CT if alignment or union in question • > 1mm displaced • > 10 degree angulation • Delay in care increases risk of displacement
Sports Medicine Scapholunate Dissociation
Sports Medicine Wrist and Hand
Most are non-operative
Sports Medicine Case
Sports Medicine Case: 5th Metacarpal Fracture
• RIGHT hand pain (right-handed dominant) • Mechanism of injury, fall off of skateboard • Landing on lateral aspect RIGHT hand • Worse with movement and gripping • Denies any prior issues with the hand
Sports Medicine Case: 5th Metacarpal Fracture
• Treated Non-operatively • Splinted 6 weeks • Excellent ROM and no need for OT
Blomberg, Joshua. “Metacarpal Fractures.” Orthobullets, 2018, www.orthobullets.com/hand/6037/metacarpal-fractures. Available at: https://www.orthobullets.com/hand/6037/metacarpal-fractures Sports Medicine Case
Sports Medicine Case: 5th Metacarpal Shaft Fracture
• Left handed • Mountain biking • Hit a tree with handle bar • 70-80% of normal motion • NO rotational deformity
Sports Medicine Case: 5th Metacarpal Shaft Fracture
• Minimal shortening • Traction to finger • Healed well • No rotation • Immobilized for 3 wks
Sports Medicine Case
Sports Medicine Case: 5th Phalangeal Fracture
Sports Medicine Lower Extremity
Sports Medicine Femur Most are operative Non-operative if non-displaced HIGH RISK of Complication Fracture of the greater trochanter
Non-operative if non-displaced lesser trochanter metastastatic cancer in older patients
Operative treatment
Most are operative Non-operative if non-displaced seen mostly in elderly
Sports Medicine Patella
Non-operative if non-displaced or minimally displaced
Sports Medicine Case: Patella Fracture
Sports Medicine Surgical or Not
• Immobilization? • Follow up?
Sports Medicine Case: Patella Fracture
• Post-op knee brace for 4 – 6 weeks • Incremental increase in range of motion • Flexion to 110 degrees by week 4 • Physical therapy for strengthening and gait training
Sports Medicine Tibia and Fibula
Most are operative Often high energy trauma
Operative treatment
Fibula and Tibia
Sports Medicine Case: Distal Tibia Fracture
• 4 yr old • “piggy back ride fall” • Unable to bear weight • Possible growth plate extension
Sports Medicine Surgical or Not
• Immobilization? • Follow up?
Sports Medicine Case: Distal Tibia Fracture
• Non-displaced • Placed in a short leg cast by Ortho • Verify stability within 1 week (re-x-ray) • Long cylinder cast 2-4 wks and additional 2-3 wk in walking cast • Possible growth plate extension so patient should have repeat x-rays every 6 months for 1-2 years to verify normal growth
Sports Medicine Ankle Mortise
Sports Medicine Case: Distal Fibula Fracture
Sports Medicine Surgical or Not
• Immobilization? • Follow up?
Sports Medicine Case: Distal Fibula Fracture
• Minimally displaced • Tall boot • Verify stability within 1 week (re-x-ray) • Weight bearing as tolerated • 6 weeks in boot • HEP or PT after to regain proprioception
Sports Medicine Case
Sports Medicine Case: Distal Fibula Fracture
Sports Medicine Surgical or Not
• Immobilization? • Follow up?
Sports Medicine Case: Distal Fibula Fracture
Sports Medicine Ankle Talus (Body/neck) 50% are operative Often high energy trauma Often non-operative if non-displaced
Talus (Lat/Post Process) Usually non-operative
Sports Medicine FOOT May be operative Non-operative Forefoot
CAUTION Lisfranc Verify proper alignment MOST are non-operative Of the TMT joints Most involve the 5th metatarsal
Midfoot About 30% are operative About 45% are avulsions treated non-operatively
Hindfoot Calcaneus Operative when displaced and articular Many are managed non-operatively (non-displaced/non-articular/process fx) Sports Medicine Case
Sports Medicine Case: 5th Metatarsal
Sports Medicine Surgical or Not
• Immobilization? • Follow up?
Sports Medicine Case: 5th Metatarsal
• Minimally displaced (< 2mm) • Non-weight bearing cast for 6 weeks • Serial x-rays • Weight bearing as tolerated • 2 weeks in cam walker boot • HEP or PT after to regain proprioception • She was running at 3 months
Sports Medicine References
• Eiff, M. Patrice. Fracture Management for Primary Care, Updated Third Edition. Elsevier, 2018. • Rockwood, Charles A. Rockwood and Green‘s Fractures in Adults, Eighth Edition, International Edition. Lippincott Williams & Wilkins, 2014. • Rockwood, Charles A. Rockwood and Wilkins' Fractures in Children, Eighth Edition, International Edition. Lippincott Williams & Wilkins, 2014.
Sports Medicine Thank You
Sports Medicine