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 1 11/5/14 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 2 11/5/14 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 -> 3 11/5/14 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??? 4 11/5/14 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) 5 11/5/14 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 6 11/5/14 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) 7 11/5/14 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 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 8 11/5/14 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! 9 11/5/14 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 Metatarsal Fractures 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 10 11/5/14 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/