Download Upper Extremity Fractures

Management of Extremity
Fractures
Bucky Boaz, ARNP-C
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
Metacarpal Fractures
• Second most common
fracture in primary care
• Classified according to
location:
–
–
–
–
Head
Neck
Shaft
Base
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
Metacarpal Fractures
• Fractures of MC neck
result from direct impact
(punching)
• Boxer’s 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 > 40º
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
Metacarpal Fractures
• Management
– Splint:
• MCP 70º to 90º of
flexion
• Use radial or ulnar
gutter
– Reduction:
•
•
•
•
Pseudocrawling
4th MC > 30º
5th MC > 40º
May not improve
outcome
Ulnar Gutter Splint
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
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
Fracture 4th metacarpal
Wrist Anatomy
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Metacarpals and phalanges
Trapezium
Carples
Scaphoid (navicular)
Distal radius
Lunate
Triquetrium
Pisiform
Capitate
Hamate
Trapezoid
Wrist Anatomy
Dorsal Anatomic Landmarks
A.
B.
C.
D.
E.
F.
G.
Radial styloid
Extensor pollicis brevis
Anatomic snuffbox
Extensor pollicis longus
Lister’s tubercle
Dorsal wrist depression
Ulnar styloid
Wrist Anatomy
Volar anatomic landmarks
A.
B.
C.
D.
E.
Radial styloid
Scaphoid tubercle
Carpal tunnel
Hamulus
Pisiform
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
Scaphoid Fracture
• Patients will complain
of wrist pain
– Particularly over
anatomic snuff box
• Swelling
• Motion is commonly
limited
Scaphoid Fracture
• Radiographs need to
include scaphoid view
– Elongates the scaphoid
along its long axis
– At least 10%-20%
false negative on x-ray
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
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)
Scaphoid Fracture
• Management
– Immobilize even if xrays negative if
warranted
– Immobilization with
thumb spica
– Ortho referral
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
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
Colles’ Fracture
• Definitive care may be
provided by primary
care provider
– Reduction of fracture
– Splinting
• Ortho referral
• Inter-articular fracture
needs ortho follow up
Smith’s 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
Galeazzi’s 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
Galeazzi’s 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 > 5mm
– Dislocation of radius
relative to ulna on lat view
Monteggia’s 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
Monteggia’s Fracture
• Radiographic:
– Ulnar fracture
– Dislocation of radial
head
– High index of
suspension required
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
Radial Head Fracture
• Radiographic:
– AP and lat
– Fat pad may be only
clue
• (occurs as a result of
distension of the
capsule by an intraarticular hemarthrosis)
– Large sail shape
abnormal
– Posterior abnormal
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
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 > 30º
Depressed > 3mm
Severely comminuted
Distal Humeral Fracture
• Described as:
– Supracondylar
– Transcondylar
– Intercondylar
• Hyperextension of
elbow during FOOSH
• AP and lat views
sufficient
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
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
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
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
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)
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
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 xrays
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)
Fractures of Tibial Shaft
• Radiologic:
– Cross-table lat and AP
– Immobilize prior to xrays if obvious fracture
• Analgesia
• Assessment of knee
and ankle
Fractures of Tibial Shaft
• Immobilization
– Long or medium posterior splint with
application of stirrups
• Elevation and ice
• Immediate ortho referral
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
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
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
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
Ankle Fractures
• Most common lowerextremity fracture
• 15% of patients
examined for ankle
injury will have a
fracture
• Successful
management requires
determination of stable
vs unstable
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
Ankle Fractures
Evolution of the Ottawa Ankle Rules
Original Ottawa Ankle Rules Refined Ankle/Foot Rules
Age>55
No age limits
Unable to bear weight (4 steps) both
immediately and in ER
Inability to bear weight (4 steps) both
immediately and in ER
Bone tenderness (at the posterior edge Bone tenderness (at the posterior edge
or top of either malleolus)
or top of either malleolus)
Bone tenderness of the navicular, the
cuboid, base of the fifth metatarsal
Bone tenderness of the navicular or
the base of the fifth metatarsal
Pain in the midfoot
Pain in the midfoot
Ankle Fractures
•
Three bones make up the
ankle joint:
1. Distal tibia
2. Distal fibula
3. 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
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
Ankle Fractures
•
Radiographic:
– AP, lat, and mortise
views
– Mortise view consists
of:
A. Medial clear space
B. Tibular/fibular clear
space
C. Tibular/fibular overlap
D. Lateral clear space
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
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
Ankle Fractures
• Treatment:
– Analgesia
– Immobilization
– Primary care can treat
Danis-Weber A
• Ortho referral
– Displacement > 2mm
– Danis-Weber B and C
– Trimalleolar (involving
both medial and lateral
malleoli and posterior lip of
tibial plafond)
– Mortise view >5mm medial
clear space
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
Fractures of the Fifth Metatarsal
• Types of fifth
metatarsal fractures:
– Avulsion fracture
– Jones fracture
(Metaphysealdiaphyseal junction)
– Apophysis
Fractures of the Fifth Metatarsal
• Nondisplaced tuberosity
fractures:
– Wooden postop shoe
– Weight bearing as tolerated
for 2-4 weeks
– Displaced >3mm ortho
referral
• Jones fracture
– Posterior splint
– Ortho referral
• All displaced Jones
fractures and intraarticular
tuberosity fractures should
be referred
Questions?