Common Fractures Family Medicine Resident School Lecture 4/5/17 - PowerPoint Presentation

Slide1

Common Fractures

Family Medicine Resident School Lecture 4/5/17

Ashley Crum, MD

Emergency Medicine/Sports Medicine Fellow

Slide2

objectives

Identify common fractures in upper and lower extremities

Treatment

Urgent vs Non-urgent

referal

Slide3

Physical Exam pearls

Try to understand the mechanism of injury from the history

Always do a neurovascular exam before and after any manipulation

Do not push for ROM testing if you suspect a fracture until you have x-rays

Slide4

Middle 3rd

clavicle fractures

Slide5

Clavicle Fractures –(Middle 3

rd

most common)

4% of all fractures

Mechanism:

direct

blow to lateral aspect of

shoulder

fall

on an outstretched arm or direct

traumaExam:Deformity present with decreased ROMImaging:X-raysCT (to better characterize fracture or vascular structures

Slide6

Clavicle fracture management

S

ling

immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks

Non-displaced middle third

Most pediatric

Stable lateral

third

Operative

Open

Non-union symptomaticSkin tentingVascular injuryUnstable fractures (posterior medial third, most lateral thirdOrtho referral: Non-emergent for most

Slide7

Proximal humerus

fractures

Slide8

Proximal Humerus

Fractures

4-6% of all fractures

Mechanism:

Low energy falls in elderly/osteoporosis

High energy mechanism in young

Neurovascular injury more likely

Exam:

Decreased ROM

Pain over proximal

humerus

Neurovascular

Imaging:

X-rays

W

hat is the most common nerve injury and why?

Slide9

Proximal

Humerus

Fracture management

Sling immobilization followed by progressive

rehab at 14 days

minimally

displaced surgical neck

fracture

greater

tuberosity fracture displaced < 5mmSurgical managementGreater tuberosity fracture displaced >5mmDisplaced surgical neck fracturesCompacted fractures with good bone qualityOrtho referral:

Urgent follow up (may call to review x-ray with)

Emergent if vascular compromise

Slide10

Humeral Shaft fracture

Slide11

Humeral Shaft fracture

3-5% all fractures

Mechanism:

Same as proximal

humerus

Exam:

Swelling, deformity

What nerve must be examined and how do you test it?

Imaging:

X-ray

humerus and above and below

Slide12

Humeral Shaft fracture management

C

oaptation

splint followed by functional

brace

Most fractures, depending on displacement

2-10% risk of non-union

Surgical

Open fracture

Vascular injuryNeurological injuryOrtho referral: non-urgent in most cases

Slide13

Distal

humerus

fractures

(Supracondylar)

Slide14

Supracondylnar fractures

Extension type 95-98%%

Flexion type <5%

Mechanism

Fall on outstretched hand

Exam

Won’t move elbow

Must check nerves, vascular (5-17% compromised)

How do you check AIN function?

Imaging

X-rays (what is the sign of occult fracture?)

Slide15

Supracondylnar

fracture management

Gartland

Classification

L

ong

arm posterior splint then long arm casting with less than 90° of elbow

flexion

Type 1 and some type 2

OperativeNeuro/vascular compromiseSevere swellingFloating elbowBrachialis signOrtho referral: usually urgent or emergent

Slide16

Other distal

humerus

fractures

Lateral epicondyle fracture

Medial epicondyle fracture

Slide17

Radial head fractures

Slide18

Radial head fractures

Most common elbow fractures (20% elbow injuries)

Mechanism

FOOSH with forearm pronated

Exam:

Tender along lateral aspect of elbow

Check all ROM

Ligament stability

What other joint should be examined??

Imaging:

X-rays

What does this image demonstrate?

Slide19

Radial head fracture management

Short period of immobilization followed by early ROM

Isolated, minimally displaced, no mechanical blocks

Can get elbow stiffness with prolonged immobilization

Surgical

Mechanical block

Other injuries

Ortho Referral: close follow up for most

Slide20

Essex-Lopresti

lesion

 

Comprised

of a comminuted 

fracture of radial head

+

dislocation

of the 

DRUJ

+interosseous membrane disruptionThe DRUJ injury may be missed leading to permanent wrist pain and stiffness.

Slide21

Galeazzi fracture Dislocation

Slide22

Galeazzi fracture Dislocation

Definition

distal

1/3 radius shaft

fx

 

AND

associated

distal radioulnar joint (DRUJ)

injury

Mechanismdirect wrist trauma dorsolateral aspectfall onto outstretched hand with forearm in pronationExamTenderness at fracture siteCheck pronation/supination for instability

Stress to DRUJ causes wrist or midline pain

Imaging

X-ray forearm, elbow, wrist

Slide23

Galeazzi management

Is Operative

Better outcomes with sooner rather than later surgery

Ortho referral

Would call for recommendations at time of presentation

Slide24

Distal Radius Fractures

Slide25

Distal radius fractures

Most common

orthopaedic

injury (50% intraarticular)

Mechanism

Young patients - high energy

older patients - low energy /

falls

Colles

: FOOSH with a pronated forearm in dorsiflexion Smith: backward fall on the palm of an outstreched hand causing pronation of upper extremity while the hand is fixed to the groundExam

Deformity, neurovascular

Imaging

X-rays

Slide26

Distal Radius fracture management

C

losed

reduction and cast

immobilization (finger trap is helpful)

extra-articular

<5mm radial shortening

dorsal angulation <5° or within 20° of contralateral distal radius

Surgical

radiographic findings indicating

instabilityOrtho Referral: need close follow up after reduction and splint. May need them to help you with a reduction

Slide27

Olecranon fracture

Slide28

Olecranon fractures

Bimodal distribution

Mechanism

direct blow: comminuted

 

fracture

fall

onto outstretched upper extremity

transverse

or oblique 

fractureExamCheck extensor mechanismDeformity of posterior elbowImagingX-ray (need a true lateral)

Slide29

Olecranon fracture management

Immobilization with early ROM at one week

Non-displaced fractures or low demand elderly individual

Splint in 45-90%

Surgical

Complex fractures

Ortho referral: close outpatient follow up (unless very complex, problems with extensor mechanism)

Slide30

Monteggia fracture dislocation

Slide31

Monteggia fracture dislocation

P

roximal

1/3 ulnar fracture with associated radial head

dislocation/instability

More

common in children 

(4-10

years

old)

Mechanism: FOOSHExamMay not be obvious, check skin integrityROM loss with dislocationWhat nerve could be affected?Imaging X-ray elbow, forearm, wrist

Slide32

Monteggia management

Adult: usually operative

Pediatric: usually closed reduction, immobilization

Can have PIN neuropathy which resolves over time

Ortho Referral:

If possible check with

ortho

prior to reduction

Slide33

Ulnar and radial shaft fractures

Slide34

Ulnar and radial shaft fractures

Mechanism

Direct trauma, athletic injury, fall from height

Exam

Large deformity

May need to check compartments

Imaging

X-rays

Treatment:

functional

fx brace with good interosseous mold for non-displaced ulnar fracturesSurgical: radial fractures, displaced ulnar fracturesOrtho Referral: Urgent if surgical or outpatient if non-displaced

Slide35

Scaphoid fractures

Slide36

Scaphoid fractures

Most common carpal bone fracture

15%

of acute wrist

injuries (waist 65% of time)

Mechanism

Axial load across hyper-extended and radially deviated wrist

Exam

Anatomic snuff box tenderness, pain with resisted ROM

What is major blood supply?

ImagingX-ray: can get scaphoid viewBone scan and MRI more sensitive

Slide37

Scaphoid fracture management

T

humb

spica

cast

immobilization

Stable, non-displaced

fractues

Surgical

Displaced fractures

Ortho referral: close outpatient follow up

Slide38

Lunate/

perilunate

dislocation

Slide39

Lunate/

perilunate

dislocation

Missed 25% of the time on initial presentation

Perilunate

: lunate stays in position while carpus dislocated

Lunate: lunate force volar or dorsal while carpus remains aligned

Mechanism

Traumatic, wrist extended and

ulnarly

deviatedExamPain and deformity of wristMedian nerve symptoms in 25% of patientsImaging X-rays

Slide40

Lunate/

perilunate

dislocation management

Always needs surgery

Emergent reduction prior to surgery can be done

Ortho referral: Urgent/Emergent

Slide41

Bennet Fracture

Slide42

Bennet Fracture- Base of Thumb

Most common variant of base of thumb fractures

Intra-articular fracture/dislocation of base of 1st metacarpal characterized

by volar

lip of metacarpal based attached to volar oblique

ligament (stays attached to trapezium)

Mechanism

Axial force applied to thumb

Exam

Pain at the base of 1

st metacarpalImagingX-rays

Slide43

Bennet Fracture Management

C

losed

reduction & cast

immobilization: non-displaced

Surgical: displaced

Ortho Referral: Urgent follow up

Epibasal

thumb fracture

Slide44

Boxers fracture

Slide45

Boxers fracture

Common in Males

Mechanism

Direct blow to hand or rotational injury with axial load

Exam

Deformity, exam for signs of rotation, break in skin

Imaging

X-ray

Treatment: usually immobilization, surgical if very angulated or shortened

Ortho referral: close follow up for cast

Slide46

Mallet (baseball) Finger

Slide47

Mallet (baseball) Finger

D

eformity

caused by disruption of the terminal extensor tendon distal to DIP

joint

Mechanism: direct blow to tip of finger causing forced flexion of DIP

Exam: finger tip rest at 45% flexion

Imaging:

xrays

Treatment

Extension splinting for 6-8 weeks with progressive flexion at 6 weeksOrtho Referral: non-urgent outpatient

Slide48

Jersey Finger

Slide49

Jersey finger

A

vulsion

injury of FDP from insertion at base of distal

phalanx

Zone

I flexor tendon

injury

Mechanism: gripping with extension force

Exam: pain over volar distal finger

Imaging: x-rayManagement: Surgical, can splint prior to surgery (<3 weeks)Ortho Referral: Needs urgent follow up

Slide50

Femoral neck fractures

Slide51

Femoral neck fractures

Increasingly more common due to aging population

Mechanism: falls in elderly, trauma in younger

Exam:

Displaced: leg

in external rotation and abduction, with

shortening

Impacted

and stress

fractures no

obvious clinical deformityImaging: x-ray (MRI for occult)Management:Non-operative if not ambulatory prior to fractureOperative otherwiseOrtho referral: Emergent if surgical

Slide52

Patella fractures

Slide53

Patella fractures

Check extensor mechanism

Management

knee immobilized in extension (brace or cylinder cast) and full weight

bearing

intact extensor mechanism

nondisplaced

or minimally displaced fractures

vertical fracture

patterns

Ortho Referral: Urgent follow up

Slide54

Pilon fracture (Tibial

Plafond

Fx

)

I

ncidence

increasing as survival rates after motor vehicle collisions increase

Mechanism: high

energy axial load

(

motor vehicle accidents, falls from height)75% have associated fibula fracturesManagement:Non-operative: minimal displacementSurgical: Most fracturesOrtho referral: Emergent

Slide55

Maisonneuve fracture

Slide56

Maisonneuve fracture

Mechanism

external

rotation force to ankle w/ transmission of the force thru the interosseous

membrane which exits

thru a proximal fibular

fracture

X-ray must obtain fibula

Management:

If stable can immobilize

Surgical for mostOrtho Referral: Urgent/Emergent

Slide57

Lateral malleolus fracture types

Slide58

Talar

Neck Fracture (aviator fracture)

Mechanism: high energy in forced dorsiflexion with axial load

Hawkins classification

I: non-displaced

II: subtalar dislocation

III: subtalar and

tibiotalar

dislocation

IV: subtalar,

tibiotalar, talonavicular dislocation(picture is type III)

Slide59

Talar Neck fractures

Imaging:

X-ray:

Canale

View (optimal for neck)

CT scan for displacement

Treatment:

ALL cases require emergent reduction

Non-displaced: short leg cast 8-12 weeks NWB for 6 weeks

Operative: all displaced fractures

Ortho referral: Emergent

Slide60

Calcaneal Fracture (Lover’s fx

)

Mechanism: traumatic axial loading

Avulsions can be due to different mechanisms (strong

gastroc

contraction or inversion plantar flexion)

Associated Injuries:

Extension to calcaneocuboid joint 63%

Vertebral injuries 10%

Contralateral Calcaneus 10%

High complication rate

Slide61

Calcaneal Fracture

Extra-articular (25%) or Intra-articular (75%)

Exam:

Diffuse tenderness

Ecchymosis

Shortened, widened, heel with a

varus

deformity

Imaging:

X-ray: reduced

Bohler angle, increased angle of GissaneCT is gold standardMRI: for stress fractures

Slide62

Calcaneal fratures

Treatment:

Stress fractures- cast with non-weight bearing for 6 weeks

Small extra-articular fracture with intact Achilles and small displacement and some intra-articular fractures –cast with non-weight bearing for 10-12 weeks

All others are operative

Subtalar arthritis increased with non-operative management

Slide63

Jones fracture

Slide64

Jones metatarsal fractures

Metaphyseal-

diaphyseal

junction

Within 1.5 cm distal to tuberosity of 5th metatarsal

High risk of non-union

ED management

Splint

NWB

Treatment

Screw fixationProlonged immobiliazation

and non-

weightbearing

Slide65

Dancer’s Fracture

Avulsion fracture at base of 5

th

metatarsal

Ankle inversion injury

Conservative treatment if non-displaced

WBAT

Slide66

Lis Franc

Slide67

Lis Franc

Axial load through a

hyperplantar

flexed foot

Injuries range from mild sprains to severe dislocations

Dislocations often associated with fractures

Metatarsal fractures in 95%

Tarsal fractures in 39%

Slide68

Lis franc

Diagnostic clues

Midfoot swelling

Plantar bruising

Fleck sign

Avulsion of

Lisfranc

ligament from base of 2nd metatarsal

Always consider compartment syndrome

Imaging: x-ray, always get stress views if you have high suspicion

MRI: for purely ligamentous injuryTreatment: Cast for 8 weeks if non-displaced and no fractureSurgery for most others

Slide69

Questions

Slide70

Ortho Referral- Fractures

Clavicle: non-emergent

Proximal

Humerus

: urgent/emergent

Humeral shaft: non-emergent

Supracondylar: urgent/emergent

Radial head: non-emergent

Galeazzi

: emergent

Distal radius: non-emergentOlecranon: non-emergentMonteggia: emergentUlnar/radial shaft: urgentScaphoid: non-emergentLunate: emergentBenett: urgent

Boxers: non-emergent

Mallet finger: non-emergent

Jersey finer: urgent

Femoral neck: emergent

Patella: urgent

Pilon: emergent

Maisonneuve: urgent

Talar

neck: emergent

Calcaneal: emergent

Jone’s

: non-emergent

Dancers: non-emergent

Lis franc: urgent

Slide71

references

Orthobullets.com

Radiopaedia.org

Wheelesonline.com