Management of Extremity Fractures

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Management of Extremity Fractures

• Bucky Boaz, ARNP-C

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Upper Extremity Fractures

• Commonly encountered in Family Practice
• Ranked 14th out of top 20 diagnoses
• 6 to 15 of orthopedic problems encountered in
  Family Practice
• Most common injuries are fractures of fingers,
  radius, metacarpals, toes, and fibula
• Many can be managed by Family Practice

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Metacarpal Fractures

• Second most common fracture in primary care
• Classified according to location
• Head
• Neck
• Shaft
• Base

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Metacarpal Fractures

• Most fractures of MC head are comminuted and need
  ortho referral
• Acute mgt
• Immobilize in ulnar or radial gutter splint
• Ice
• Elevation
• Analgesia
• Ortho evaluation within 1 week of injury

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Metacarpal Fractures

• Fractures of MC neck result from direct impact
  (punching)
• Boxers Fracture
• Head of MC is displaced volarly
• Tenderness and swelling over dorsum of hand
• Possible pseudocrawling
• Hyperextension at MCP and flexion at PIP
• Dorsal angulation gt 40º

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Metacarpal Fractures

• Radiographs AP, lat and oblique views
• Degree of angulation on lateral view
• Expected 15º
• Subtract from visualized angulation
• More distal greater allowed
• Deformity better tolerated in 4th or 5th digits

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Metacarpal Fractures

• Management
• Splint
• MCP 70º to 90º of flexion
• Use radial or ulnar gutter
• Reduction
• Pseudocrawling
• 4th MC gt 30º
• 5th MC gt 40º
• May not improve outcome

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Metacarpal Fractures

• Reduction
• Hematoma or ulnar nerve block
• 90-90 method
• MCP, PIP, DIP joints flexed 90º
• Volar-directed pressure over fracture site
• Immob with wrist extension 30º and MCP flexed to
  90º

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Metacarpal Fractures

• Nondisplaced fractures of 2nd and 3rd MCs follow
  up x-ray within 4-5 days
• Fractures to 4th or 5th MCs follow up x-ray 7-10
  days
• Any change, ortho referral
• No contact sports for 4-6 weeks after
  immobilization

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Wrist Anatomy

• Metacarpals and phalanges
• Trapezium
• Carples
• Scaphoid (navicular)
• Distal radius
• Lunate
• Triquetrium
• Pisiform
• Capitate
• Hamate
• Trapezoid

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Wrist Anatomy
Dorsal Anatomic Landmarks

• Radial styloid
• Extensor pollicis brevis
• Anatomic snuffbox
• Extensor pollicis longus
• Listers tubercle
• Dorsal wrist depression
• Ulnar styloid

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Wrist Anatomy
Volar anatomic landmarks

• Radial styloid
• Scaphoid tubercle
• Carpal tunnel
• Hamulus
• Pisiform

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Scaphoid Fracture

• Most commonly fractured carpal bone
• 70 - 80 of all carpal bone injuries
• 8 of all sports-related fractures
• Spans both carpal rows
• Susceptible to injury when stress applied to
  dorsiflexed wrist

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Scaphoid Fracture

• Patients will complain of wrist pain
• Particularly over anatomic snuff box
• Swelling
• Motion is commonly limited

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Scaphoid Fracture

• Radiographs need to include scaphoid view
• Elongates the scaphoid along its long axis
• At least 10-20 false negative on x-ray

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Scaphoid Fracture

• Anatomical Importance
• Blood supply from a branch of radial artery
  enters the distal pole
• Retrograde blood flow
• Fractures at risk of nonunion or AVN
• Proximal
• Oblique
• displaced

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Scaphoid Fracture

• Examination
• Anatomic snuff box swelling or pain on palpation
• Pronation and ulnar deviation exacerbates pain
• Axial loading exacerbates pain
• Pronation/supination against resistance
  exacerbates pain (supination more specific)

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Scaphoid Fracture

• Management
• Immobilize even if x-rays negative if warranted
• Immobilization with thumb spica
• Ortho referral

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Colles Fracture

• Most common fracture of the distal radius
• Results from a fall on an outstretched hand
  (FOOSH)
• Dorsal swelling
• Eccymosis
• Silver fork deformity of the hand and wrist

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Colles Fracture

• Radiographs
• (AP, lat, oblique)
• Apex volar fracture with dorsal comminution and
  shortening of the radius
• Typically occurs within 2cm of distal radius
  articular surface

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Colles Fracture

• Definitive care may be provided by primary care
  provider
• Reduction of fracture
• Splinting
• Ortho referral
• Inter-articular fracture needs ortho follow up

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Smiths Fracture

• Less common fracture of distal radius
• Unstable fracture
• Distal fragment is displaced volarly and
  proximally (apex dorsal)
• Direct blow to dorsum of the wrist
• Splint and immediate ortho referral

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Galeazzis Fracture

• Radial shaft fracture at junction of middle and
  distal thirds with disruption of distal
  radioulnar joint
• Fall on extended pronated wrist
• Suspect if tenderness at distal radius and distal
  radial ulnar joint (DRUJ) disruption

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Galeazzis Fracture

• Radiographic
• Transverse or oblique fracture at junction of
  middle and distal thirds seen on AP view
• Widening of DRUJ on AP view
• Fracture of base of the ulnar styloid
• Radial shortening gt 5mm
• Dislocation of radius relative to ulna on lat view

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Monteggias Fracture

• Fracture of ulnar shaft with dislocation of
  radial head
• Fall on outstretched, extended, and pronated
  elbow is usual mechanism
• Radial head may be palpated in antecubital fossa
• Radial nerve neuropraxia

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Monteggias Fracture

• Radiographic
• Ulnar fracture
• Dislocation of radial head
• High index of suspension required

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Radial Head Fracture

• Result from FOOSH or valgus compressive force
• May occur in elbow dislocation
• Swelling lat aspect
• Limited ROM
• Maximal tenderness over radial head

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Radial Head Fracture

• Radiographic
• AP and lat
• Fat pad may be only clue
• (occurs as a result of distension of the capsule
  by an intra-articular hemarthrosis)
• Large sail shape abnormal
• Posterior abnormal

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Radial Head Fracture

• Treatment non-displaced fracture
• Immob in long-arm posterior splint with elbow
  flexed 90º.
• Ice and elevation for 48 hours
• Analgesia
• Forearm rotation out of splint 3-5 days
• 1 week sling for comfort only
• Active ROM

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Radial Head Fracture

• Most common complication
• 10º to 15º limit to ROM
• Does not limit function
• Immediate ortho referral criteria
• fracture dislocation
• brachial artery or nerve injury
• 2mm displacement
• 1/3 of articulating surface
• Angulated gt 30º
• Depressed gt 3mm
• Severely comminuted

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Distal Humeral Fracture

• Described as
• Supracondylar
• Transcondylar
• Intercondylar
• Hyperextension of elbow during FOOSH
• AP and lat views sufficient

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Distal Humeral Fracture

• Helpful landmark on lat view is extension of
  anterior humeral line through the capitellum
• Line should transect middle of capitellum
• Supracondylar fracture
• Transects anterior third
• Falls completely anterior

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Distal Humeral Fracture

• Most important aspect
• Assess neurovascular
• All three major nerves of arm or brachial artery
  may be injured
• Immediate referral for any compromise
• Long-arm posterior splint arm flexed 90º

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Clavicle Fracture

• Approx 5 of all primary care fractures
• Typical mechanism of injury
• FOOSH
• Fall onto shoulder
• Direct clavicle trauma
• Patient complains of pain with any shoulder
  movement and holds arm against chest

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Clavicle Fracture

• Physical exam
• Edema
• Point tenderness over fracture site
• May have crepitus
• Possible fragment motion
• Possible eccymosis
• Possible tenting of skin
• Careful, passive range of motion should be
  tolerated
• Motor strength should be intact

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Clavicle Fracture

• Radiographic
• AP and 45º cephalic tilt views
• Medial portion often displaced upwards
• Treatment
• Reduction of motion
• Less than 45º abduction
• Sling or figure eight
• Continue until no crepitus or pain over site.
  (4-8w)

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Clavicle Fracture

• Avoid contact sports or risk of falls for 6
  additional weeks
• Ortho referral
• Neurovascular compromise
• Open fracture
• Integrity of skin in jeopardy
• Uncontrolled deformity
• Cosmesis
• Nonunion after 12 weeks

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Lower Extremity Fractures

• Examination for
• presence of gross deformity
• Loss of pulses
• Impaired neurologic function distal to injury
• Ankle injuries account for 10 of all ER x-rays

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Fractures of Tibial Shaft

• Most commonly fractured long bone
• Associated with complications
• Time to union
• 20 wks rods
• 14.7 wks cast
• 13 wks ORIF (higher rate of complications)

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Fractures of Tibial Shaft

• Radiologic
• Cross-table lat and AP
• Immobilize prior to x-rays if obvious fracture
• Analgesia
• Assessment of knee and ankle

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Fractures of Tibial Shaft

• Immobilization
• Long or medium posterior splint with application
  of stirrups
• Elevation and ice
• Immediate ortho referral

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Proximal and Midshaft Fibular Fractures

• Fibula not significantly involved in weight
  bearing
• Prox fib attachment site for lateral collateral
  ligament and biceps femoris
• Examine to rule out Maisonneuve fracture

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Proximal and Midshaft Fibular Fractures

• Proximal fibular fractures indicate knee
  instability until proven otherwise
• May be associated with peroneal nerve injury
• Test dorsiflexion and sensation of 1st web space

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Proximal and Midshaft Fibular Fractures

• Radiographic
• Lateral and AP views
• Look for tibial plateau fracture
• Treatment
• In sensory or motor disfunction, post splint and
  ortho follow-up

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Proximal and Midshaft Fibular Fractures

• Treatment
• Small avulsion and nondisplaced fractures of fib
  neck, knee immob and crutches
• Hinged knee brace when comfortable
• 4-6 wks protection from lateral motion

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Ankle Fractures

• Most common lower-extremity fracture
• 15 of patients examined for ankle injury will
  have a fracture
• Successful management requires determination of
  stable vs unstable

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Ankle Fractures

• The bones and ligaments of the ankle form a ring
  around the ankle mortis
• For instability to occur, ligamentous injury or
  fracture must include both medial and lateral
  sides of the ring
• Isolated distal fib or tib fractures are stable
  if no ligamentous instability on opposite side of
  ring

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Ankle Fractures
Evolution of the Ottawa Ankle Rules
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Ankle Fractures

• Three bones make up the ankle joint
• Distal tibia
• Distal fibula
• Talus
• Relationship of the tibial plafond (joint
  surface) to the talus in important for ankle
  stability
• Determining ankle position during injury can
  assist in assessment

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Ankle Fractures

• Medial complex injuries occur from eversion force
• Lateral complex injuries occur from inversion
  force
• Most common ankle injury
• Posterior malleolus injury is found with a
  combination of forces

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Ankle Fractures

• Radiographic
• AP, lat, and mortise views
• Mortise view consists of
• Medial clear space
• Tibular/fibular clear space
• Tibular/fibular overlap
• Lateral clear space

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Ankle Fractures

• 5 most commonly missed foot and ankle fractures
  (FLOAT)
• Fifth metatarsal base
• Lateral process of talus
• Os trigone (post mall)
• Anterior process of calcaneous
• Talar dome

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Ankle Fractures

• Danis-Weber Classification of Fibular Fractures
• Type A are horizontal avulsion fractures found
  below the mortise
• Type B starts at the level of the mortise (stable
  or unstable depending on ligaments)
• Type C fracture is above the level of the mortise
  and disrupts the ligaments between the fibula and
  tibia

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Ankle Fractures

• Treatment
• Analgesia
• Immobilization
• Primary care can treat Danis-Weber A
• Ortho referral
• Displacement gt 2mm
• Danis-Weber B and C
• Trimalleolar (involving both medial and lateral
  malleoli and posterior lip of tibial plafond)
• Mortise view gt5mm medial clear space

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Fractures of the Fifth Metatarsal

• Most common fracture to base of Fifth metatarsal
  is results from inversion ankle injury
• The peroneus brevis tendon insertion causes an
  avulsion of the proximal portion
• Physical exam should include palpation over the
  base of the fifth metatarsal for all ankle
  injuries

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Fractures of the Fifth Metatarsal

• Types of fifth metatarsal fractures
• Avulsion fracture
• Jones fracture (Metaphyseal- diaphyseal junction)
• Apophysis

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Fractures of the Fifth Metatarsal

• Nondisplaced tuberosity fractures
• Wooden postop shoe
• Weight bearing as tolerated for 2-4 weeks
• Displaced gt3mm ortho referral
• Jones fracture
• Posterior splint
• Ortho referral
• All displaced Jones fractures and intraarticular
  tuberosity fractures should be referred

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Questions?