Download Office Fracture Care - University of Michigan

Office Fracture Care
TARA MASTERHUNTER, M.D.
DEPT. OF FAMILY
MEDICINE
UNIVERSITY OF
MICHIGAN
OCTOBER 2016
Objectives:
 To gain understanding of the risks of fracture care.
 To improve the ability to triage fractures and
understand which ones may need orthopedic
referral.
 To improve awareness of commonly missed injuries.
Refer to an orthopedist for any of the following:
 Intraarticular
 Severe comminution
 Inability to maintain reduction
 Nerve or vascular injury
 CRP
 Open Fractures
 Nonunion
 Pathologic fractures
Other fracture concepts
 Lack of tenderness to percussion is a sign of clinical
healing
 In the elderly, immobilize as briefly as possible and
rehab
 Check and document neurovascular status at every
visit
Case #1: Fall on an Outstretched Hand
30 yo male injures
his wrist after
falling on an
outstretched hand.
He was learning
how to roller blade
(saw it on extreme
sports channel).
Common FOOSH Injuries
 Distal Radius
Fractures (Colles’
fracture)
 Scaphoid Injuries
 ouch
Distal Radial (Colles’) Fracture
 Distal radial
compression
fracture with
dorsal
angulation
 Stable if <20o
dorsal
angulation
Distal Radial (Colles’) Fracture
Stable if <10mm
shortening
23o
normally 12mm
Classification of Distal Radial (Colles’) Fracture
 Frykman Classification
 I/II extraarticular
 III/IV radiocarpal joint
 V/VI radioulnar joint
 VII/VIII radiocarpal and
radioulnar joint
summit.stanford.edu
/.../Frykman_slide12.gif
Colles’ Fracture-Nondisplaced
 Acute Tx: Volar splint or sugar tong splint for 3-5
days
 Definitive Tx: short arm cast (SAC) 4-6 weeks
 X-ray every 2-3 weeks
Other Distal Radial Fractures
 Smith’s: Distal radius
fracture with VOLAR
angulation (reverse
Colles’)
http://3.bp.blogspot.com/_v4G5cCgKDT0/S3cK4OTRQjI/AAAAAAAAAC8/JKck
u6vcIAk/s1600-h/Smith+Fracture
Other Distal Radius Fractures
 Barton’s Fracture:
Distal radial
articular surface
is sheared off with
disruption of the
joint.

://www.radiologyassistant.nl/images/477a5a2b8
f5f6Barton-volar.jpgar.jpg
Other Distal Radius Fractures
 Galeazzi’s: radial shaft
fracture at the junction of
the middle and distal
thirds with disruption of
the distal radialulnar
joint
http://emedicine.medscape.com/article/1239331-overview
Scaphoid
Injuries
OUCH
Scaphoid Fracture
 Tenderness at anatomic
snuffbox
 X-rays are often normal
for nondisplaced
fractures
 Blood supply arises
distally, so middle and
proximal fractures can
lead to AVN, consider
referral
 Look for scapholunate
dissociation
http://www.aafp.org/af
p/2004/0901/afp20040
901p879-f2.jpg
http://img.orthobullets.com/Hand/Fractures/Scaph
oid%20fx/Images/Blood%20supply%20TTC.jpg
Scapholunate Dissociation
 “Terry Thomas sign” - >3mm gap
between scaphoid and lunate,
consider MRI arthrogram for
definitive diagnosis
 Must be referred to ortho for
surgery
 Postive Watson’s
test
Scaphoid
Lunate
.
www.maitrise-orthop.com/.../figures/fig22.JPEG
Scaphoid: Treatment
 Suspected fx or distal fx:
Short arm thumb spica
cast or splint until
diagnosis confirmed
 X-ray in 2 weeks, if still
unconfirmed then bone
scan, CT or MRI
 Discuss risk of AVN
Scaphoid: Treatment
 Nondisplaced distal
fracture: Long or
short arm thumb
spica cast or splint
for 6 weeks then,
Short arm thumb
spica cast for 4-6
weeks. Consider
referring proximal
fractures
http://www.aafp.org/afp/2004/0901/afp20040901p879-f1.jpg
Case #2: Jim the Tool Man
 30 yo male, well
known to you,
decides to give up
sports, but, after
watching many
episodes of ‘The New
Yankee Workshop,’
wants to start
building furniture.
Guess what
happens….
Common Hand Fractures
Metacarpal
Finger
OUCH
Metacarpal Concepts
 Cog joint
 Rock in the glove: 4th and 5th CMC’s move, 2nd and
3rd don’t
 Look for teeth
Rockwood & Green's Fractures in Adults, 4th ed., Copyright © 1996 Lippincott-Raven Publishers
Metacarpal: Referral Indications
 Neck:


>40o angulation for the 5th
>30o for the 4th
 Shaft:


>20o for the 5th, >10o for
the 4th
>5mm shortening of
oblique Fx
http://www.wheelessonline.com/image5/box2.jpg
Metacarpal: Referral Indications
 CANNOT TOLERATE ANY ANGULATION OF
THE 2ND OR 3RD METACARPALS
 Base: 5th metacarpal base is unstable
Malrotation
Malrotation - check to see that all
fingers point to the radial styloid
Rockwood & Green's Fractures in Adults, 4th ed., Copyright ©
1996 Lippincott-Raven Publishers
Metacarpal Fx
 Acute and definitive Tx:
Radial or ulnar gutter
splint
 MCP at 90o flexion and
wrist at 30o extension
http://www.eorthopod.com/images/ContentImages/Fractures/adult_fractures/ad
ult_hand_fx/adult_hand_fx_ulnar_gutter_splint.jpg
Finger Fractures
 Always check lateral
stability and flexor and
extensor strength
(avulsion fractures
aren’t always seen on
X-ray)
Finger: Referral Indications
 Malrotation
 Oblique or spiral fractures
 >25-30% articular involvement
 >2mm displacement
Flexor & Extensor Avulsions
Boutonniere
Volar plate
Mallet
Jersey
Grey’s Anatomy
Flexor Avulsions
 Distal phalanx flexor
(Jersey)

Splint in partial flexion and
refer immediately
www.aafp.org/afp/2006/0301/afp20060301p810-4.jpg
Flexor Avulsions
 Middle phalanx flexor
(Volar plate)

Nondisplaced- buddy tape
or dorsal splint (PIP free)
in partial flexion until
healed
Extensor Avulsions
 Distal phalanx extensor
(Mallet)

splint in extension
continuously for 6-8 weeks
www.aafp.org/afp/2006/0301/afp20060301p810-4.jpg
http://orthoinfo.aaos.org/figures/A00018F02.jpg
Extensor Avulsions
 Middle phalanx extensor
(Boutonniere)


splint in extension
continuously for 6 weeks
then nightly for 3-4 weeks
Refer large avulsions & late
presenters
cprtherapy.org/.../finger_bouton_diagnosis01.jpg
http://www.wheelessonline.com/image8/bout2.jpg
Finger: Shaft Fractures
 Nondiplaced – Splint or
buddy tape for 3-4 weeks
 Referral indications:




Malrotation
Oblique or spiral fractures
>25-30% articular
involvement
>2mm displacement
http://schneiderorthopaedic.com/low%20res/low%20res/finger%20safe.jpg
Case #3: Ankle Injury
 29 yo female tries to
train for her first
marathon, but
instead twists her
ankle while walking
out of her house.
Ankle Injuries
 Radiographs for ankle injuries comprise 10% of all x-
rays taken in the ER
 Ankle injuries are the most common lower extremity
injury seen in primary care practices
 Although injuries are common, evaluation can be far
from simple
Ankle Stability
 Ankle is most stable in
dorsiflexion since talus
and tibial plafond are
wider anteriorly
 Subtalar inversion limited
by interosseous ligament,
peroneal tendons, lateral
ankle ligaments
 Subtalar eversion limited
by deltoid ligament
posterior tibial tendon,
anterior tibial tendon
Ankle Injuries
 Ring of Ankle
Mortise
 One break of the ring
should raise
suspicion of other
injury
 In general, only one
break in the ring
maintains stability
Ankle Injury
 Mechanism of Injury
 Direction of force and position of foot often dictate
pattern of injury
 Determining stability is key in managing and
considering referral for ankle injuries
Physical Exam
 Areas of tenderness and swelling
 Check for significant medial or lateral pain
 Evaluate ability to stand or walk
 Anterior drawer test
 Talar tilt test
 Squeeze test
 External rotation stress test
Anterior Drawer Test: ATFL ligament
http://orthoontheweb.com/images/Ankle_ATF_drawer_arrow_300w.JP
G
Talar Tilt Test: CF ligament
http://orthoontheweb.com/images/Ankle_CF_drawer__w_arrow_300w.JPG
Squeeze Test: Syndesmosis
http://www.hawaii.edu/medicine/pediatrics/pemxray/v3c03h.jpg
External Rotation Stress Test
http://mostlymassagezine.com/wp-content/uploads/2006/03/ankle-4-150x150.jpg
Ottowa Rules
 Inability to bear weight (4 steps) immediately and in
office
 Bony tenderness at posteror edges or tip (distal 6
cm) of either malleoli
 Bony tenderness at base of 5th metatarsal or
navicular
 (Pain in midfoot)
Ottowa Ankle Rules
 Not 100% sensitive, may miss small avulsion
fractures
 More effective at ruling out fracture than ruling one
in, negative predictive value 99%
 Intended to be applied in the acute setting
Radiographs
 Standard: AP, lateral, mortise
 Studies suggest 95% of fractures can be seen on
lateral and either AP or mortise view
 Avulsion fractures are usually transverse, talar
impact fractures are usually oblique
Radiographs: Evaluating Instability
 Medial Clear Space:
 on the mortise view look
for space between the
lateral border of medial
malleolus and medial
border of talar dome.
Should be equal to space
between talus and plafond
and lateral malleolus or
less than 4mm
 If evaluated with foot in
plantarflexion can get false
widening
Radiographs:
 Without medial
injury, acceptable
lateral malleolar
fracture
displacement is less
than 2mm.
Indications for Referral
 Unimalleolar fracture:






Displaced medial or lateral
malleolar fractures
Medial (or lateral) malleolar
fractures with significant lateral (or
medial)collateral ligament injury
Lateral malleolar fractures with
widened medial clear space
Unimalleolar fracture with
syndesmotic diastasis
Fibular fracture at or proximal to
the tibiotalar joint line
Displaced posterior malleolar
fracture or involving more than 25%
of joint space
 Bimalleolar fractures
 Trimalleolar fractures
 Intraarticular fractures
with step deformity
 Open fractures
 Pilon fractures
Treatment:
 Isolated Nondisplaced
Malleolar Fracture



Initial: Posterior splint
Definitive: Short leg cast
for 4-6 weeks
Consider rehab after
coming out of cast
https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcSdi_vKGbdQwMtZQgZ-UxlNnQvit-Yvrt89Oi7A5sp06clOyQJR
Frequently Missed Fractures
 Fractures of the base of




the 5th metatarsal
Lateral process of talus
Anterior process of
calcaneous
Talar dome
Lisfranc injuries
Talus: Lateral Process





Severe inversion, dorsiflexion
Tenderness anterior and inferior
to lateral malleolus
Best seen on mortise view.
Refer if displaced >3mm or
involving subtalar articulation
Small nondisplaced fracture
with <10% joint involvement
can be treated symptomatically
with cast boot or SLWC for 6
weeks
http://www.aofas.org/news-enter/pressreleases/PublishingImages/symp_Pic1.jpg
Talar Dome Osteochondral Lesions



49% incidence of injury to articular cartilage of talar dome
with malleolar fractures
Suspect with persistant pain with weight bearing, persistant
swelling, locking or crepitance
Often need CT or MRI to determine extent of injury
Talar Dome OCD Lesions

Stage I-IV






I: small area of compression of
subchondral bone
II: lesion partially attached but
nondisplaced
III: lesion completely detached but
nondisplaced
IV: lesion displaced.
Stages III and IV need referral
to orthopedics
Symptomatic stage I and II
treat with decreased activity,
limited weight bearing or
immobilization for up to 6-8
weeks
Anterior Process of Calcaneus
 Best seen on a lateral view
 Usually avulsion fracture at the
site of the bifurcate ligament
attachment from adduction and
plantarflexion of the foot
 Swelling and tenderness just
distal to lateral malleolus
 Refer large or displaced fractures
 Treatment: Nondisplaced
fractures immobilize in SLWC
for 2-4 weeks
http://www.aafp.org/afp/2002/0901/afp20020901p785-f9.jpg
Midfoot injury: Lisfranc Injury



AP: medial border of the
2nd metatarsal and medial
border of medial
cunieform should line up
Oblique: medial border of
4th metatarsal lines up with
medial border of cuboid,
continuous line with the
lateral border of the 3rd
metatarsal and the lateral
cunieform
Lisfranc ligament anchors
the 2nd metatarsal base to
the medial cunieform
Lisfranc Injury
 Injury involving the
tarsalmetatarsal joint
 20% misssed on xray,
may need CT/MRI for
diagnosis
 Often presents with
inability to bear weight,
especially stand on toes,
and severe midfoot pain
 Require referral to
orthopedics
Lisfranc Injury

Widening of the space
between the 1st and 2nd
and 2nd and 3rd
metatarsals

Fleck sign
Lisfranc Injury

Fracture of the base of
the 2nd metatarsal is
pathognomic for
Lisfranc injury
Case #4: Reading time
 29 yo female after
having her cast
removed decided to
get back to work…..of
course she injures
herself when she
drops her reading
material on her foot.
Foot Fractures: Forefoot
 Metatarsal
 Phalangeal
Metatarsal Fractures
 Metatarsal Shaft Fractures
 Often due to direct blow or twisting
 Difficulty weight bearing and tenderness over fracture site
 Standard radiographs: AP, lateral and oblique
Metatarsal Shaft Fractures
 Evaluate for dorsal apex
angulation
 Displaced fractures of first
metatarsal, displaced multiple
metatarsal fractures, intraarticular
fractures and those close to the
head should be referred
 Nondisplaced shaft fractures can
be treated with firm soled shoe,
post op shoe, or SLWC for 4-6
weeks
http://www.aafp.org/afp/2007/0915/afp20070915p817-f10.jpg
Proximal 5th Metatarsal Fractures

Proper triage of fractures of this area are key to
successful treatment

Evaluate with the standard foot series

Determine which “zone’ area the fracture involves
Proximal 5th Metatarsal Fractures
Fracture lines are
usually transverse or
oblique to the long
axis of the shaft
 The apophysis is
usually parallel to
shaft and is present
between the ages of 913

http://www.aafp.org/afp/2007/0915/afp20070915p817-f3.jpg
Proximal 5th Metatarsal Fractures
 Zone I:
 Avulsion fractures of
the tuberosity
 Due to peroneus
brevis or plantar fascia
with ankle inversion
injury
 Tenderness over base
of 5th metatarsal
Proximal 5th Metatarsal Fractures
Nondisplaced
fractures treat with
post op shoe or SLWC
for 2 weeks
 If displaced >3mm or
involving 30% of
articular surface
consider orthopedic
referral

Proximal 5th Metatarsal Fractures
 Zone II
Jones Fracture
 Usually from a laterally directed
force on plantarflexed foot
 Watershed area for blood supply
 Treatment:
 NWBSLC for 6 –8 weeks
 Consider referral to orthopedics
for ORIF, especially in elite level
athletes

http://www.athleticadvisor.com/injuries/le/foot&ankle/jones_fracture.htm
Foot Fractures: Toes
 Fractures to the 2nd
to 5th toes generally
to well with buddy
taping
 Fractures to 1st toes
usually due to axial
compression or direct
blow
http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/media/medical/hw/h9991553_001.jpg
Refer to an orthopedist for any of the following:
 Intraarticular
 Severe comminution
 Inability to maintain reduction
 Nerve or vascular injury
 CRP
 Open Fractures
 Nonunion
 Pathologic fractures
Other Fracture Concepts
 Always look at the radiographs yourself
 Be aware of potential poor outcomes
 Manage fractures that you are comfortable with