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COMMON FRACTURES: RECOGNITION AND MANAGEMENT AAFP Board Review 2006 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] I. Fracture Terminology A. Open vs closed B. Simple vs comminuted C. Intra-articular vs extra-articular D. Fracture Patterns · Transverse · Oblique · Spiral · Impacted · Longitudinal E. Anatomic Fracture Description · Displacement · Angulation · Rotation · Separation F. Special Pediatric Fracture Patterns · Greenstick · Torus · Plastic Deformation · Physeal Injuries

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COMMON FRACTURES: RECOGNITION AND MANAGEMENT AAFP Board Review 2006 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected]

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II.

Upper Extremity

A. Clavicle Fractures 1. Mechanism = fall on outstretched hand or directly on lateral aspect of shoulder. 2. Classification: · Proximal third · · Middle third (most common) Distal third

3. PE- pain to palpation of clavicle + deformity and crepitus. 4. Dx- H&P, Xrays- usually a superior displacement of the proximal fragment by the sternocleidomastoid m. 5. Rx- Most proximal and middle fx respond well to figure-of-eight bracing or clavicular strapping. Distal fx with significant displacement may require REFERRAL to orthopedics. However, most distal fx can be managed appropriately by family physicians. Figure-of-eight or sling for 34 weeks in children, 4-8 weeks for adults. When clinical healing start ROM exercises to pain tolerance. Expect exuberant callus formation. May cause compression of neurologic structures underneath (brachial plexus) at 2-3 months. Rx for this is resection of callus. REFER any

COMMON FRACTURES: RECOGNITION AND MANAGEMENT AAFP Board Review 2006 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] severely displaced or comminuted fx.

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B. Proximal Humerus fractures- good blood supply to the proximal humerus allows for better healing of fractures in this region. Beware fracture-dislocation. 1. Hx-most occur in elderly from fall on outstretched hand. Patients may have a h/o osteoporosis or falls risk. Generalized pain to the shoulder region with lack of interest in moving upper arm/shoulder may be the only history. 2. PE- fairly nonspecific. Inability to move upper extremity, + ecchymosis to shoulder region. 3. Rx- fractures with no or minimal displacement are treated with nonoperative methods. The mainstay in this case is immobilization from 1-3 weeks, and pain control/comfort measures. Early gradual mobilization (3 weeks) improves mobility and reduces risk of adhesive capsulitis. REFERRAL for surgical treatment is indicated if comminuted fractures, younger patients or fracture-dislocation. C. Supracondylar Fractures of the Elbow: Supracondylar fractures are one of the most common types of fracture seen in children, especially 5-8 years of age. They can be particularly concerning to the treating physician because of their potential for neurovascular compromise and cosmetic deformity. Roughly 5% will have concomitant distal radius fractures. Gartland ClassificationType I: no displacement Type II: minimal displacement (intact posterior cortex) Type III: moderate displacement 1. Hx- mechanism of injury = fall on outstretched hand with elbow in hyperextension (95%). 2. PE- child will not move elbow. ++ swelling, + ecchymosis. Also examine distal radius to r/o pain/fracture. 3. Dx- interpretation of the radiographs can be difficult due to subtle fracture lines and variability in the appearance of secondary centers of ossification. Consider obtaining xrays of the contralateral, uninjured elbow (comparison views). When a fracture line is not visible in an obviously injured elbow, analysis of fat pad signs and the anterior humeral line can be used to determine the likelihood of an occult fracture. Special Considerations in Reviewing Pediatric Elbow Xrays · Fat Pads: The posterior fat pad sits in the olecranon fossa and is not visible on a true lateral projection of a normal elbow. When a radiolucent (dark) stripe is visible in this area, a posterior fat pad sign is present. A visible posterior fat pad is associated with fracture of the elbow in 80 to 100% of cases. The presence of a posterior fat pad is always pathologic. The anterior fat pad sits in the shallower coronoid fossa and therefore

COMMON FRACTURES: RECOGNITION AND MANAGEMENT AAFP Board Review 2006 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] is sometimes visible on lateral elbow films as a thin radiolucent (dark) stripe overlying the distal anterior humerus. With traumatic injury, joint effusion lifts the fat pad from its normal position creating a "sail" shape. · Anterior Humeral Line-The anterior humeral line (AHL) is visualized on a lateral radiograph by drawing a line along the anterior cortex of the humerus through the capitellum. Another line can be drawn on the lateral xray along the radius, also intersecting with the capitellum. The AHL normally intersects the capitellum in its posterior two-thirds. Hyperextension of the elbow that causes a supracondylar fracture typically causes posterior angulation of the distal portion of the humerus resulting in an AHL that intersects the capitellum in its middle one-third.

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4. Rx- elbow fractures in pediatric population may require orthopedic consultation. Type I (nondisplaced fractures) are usually treated nonoperatively with posterior elbow splint at 90o. Type II and II supracondylar fractures are usually treated surgically. Complications(especially with displaced fractures)neurovascular compromise (including Volkmann's contracture), permanent angulation deformities. D. Monteggia Fracture-Dislocation 1. Definition- fracture of the shaft of the ulna (especially the proximal third) associated with radial head dislocation. Hx- Pain and diminished motion at the elbow. 2. PE- significant tenderness and swelling throughout the elbow and forearm; Check neurologic and vascular function distally. 3. Dx- xrays will show this fracture-dislocation well, especially the lateral view. Consider comparison views of unaffected side if necessary. Consider wrist films in addition to elbow films. 4. Rx- elbow fractures in pediatric population should have orthopedic consultation. In children, most can be treated with closed reduction. Of primary importance is the reduction of the radial

5 COMMON FRACTURES: RECOGNITION AND MANAGEMENT AAFP Board Review 2006 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] head dislocation. When the capsule or annular ligament prevent the radial head from relocating, surgical intervention is required. If anatomic reduction of radial head and ulna are achieved, the elbow is immobilized in ~ 100o of flexion and full supination. Also, most authors agree that Monteggia injuries in adults need to be surgically treated. Complications include neurovascular compromise, angular deformities. E. Distal Radius 1. Colles Fracture (distal radius with dorsal angulation): Fall on outstretched hand in hyperextension. PE with obvious "silver fork" deformity, edema and ecchymosis. Beware coexistent ulnar fracture, distal radioulnar joint (DRUJ) subluxation/dislocation, median nerve palsy and referred injury. Xray consistent with above. Assess follow-up xrays at 2-4 weeks for delayed displacement, angulation, shortening of radius and callous formation. Treatment as below: · Undisplaced, minimal angulation: short arm cast (with wrist in slight flexion and ulnar deviation) for 4-6 weeks. · Mild displacement/angulation > 5 mm loss of radial height, and >10 o dorsal tilt of distal radius (normal wrist has ~ 10-15o of volar tilt): long arm cast while maintaining traction. Manipulation via distraction and volarly directed force. Obtain post-manipulation xrays. Consider weekly xrays for 3-4 weeks if manipulation required. If difficult to maintain anatomic reduction, REFER to surgeon. Some authors advocate referral of any fx requiring manipulation. · Moderate-to-severe displacement/angulation or associated injuries (DRUJ dislocation, median nerve palsy, etc.), REFER to surgeon. 2. Smith's Fracture (distal radius with volar angulation) AKA reverse Colles: Mech = fall on back of flexed hand. Much less common than Colles fx. Xrays demonstrate volar angulation. If fx line is transverse (type I), treatment with short arm cast for 4-6 weeks. 3. Torus and Greenstick Fractures- also check for concomitant ulnar injuries. Treatment the same as above. REFER large displacements and angulation (> 30-40). Expect quicker healing in this pediatric age group than with fractures above. 4. Radial Styloid Fracture- (AKA Chauffeur's fracture: kick-back on hand crank to start engine struck forearm)-minimal displacement, angulation = cast immobilization. REFER for displacement, angulation. Note- consider short-arm thumb spica cast in the above situations if significant pain with thumb movements, and long-arm thumb spica cast if significant pain with supination/pronation movements.

COMMON FRACTURES: RECOGNITION AND MANAGEMENT AAFP Board Review 2006 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected]

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F. Scaphoid Fracture 1. Mech = fall on outstretched hand with wrist in hyperextension. 2. Classification - Proximal pole (30%), waist (most common, 50-60%), distal pole and tubercle (the latter two combined account for 10% of all scaphoid fx). Vasculature often enters from the distal pole, running proximally. Fractures, therefore, of the proximal pole are at risk (30%) for avascular necrosis. This phenomenon is immediate in onset, but may take 1-2 months to become visible on xray. 3. PE = pain in anatomic snuffbox and/or palmarly. Decreased ROM. 4. Radiology - AP, lateral; oblique and scaphoid (AP in ulnar deviation) views can be helpful. If negative, repeat at 2-4 weeks or obtain bone scan. Diagnosis requires high clinical suspicion. If tenderness and negative radiography, treat as if fx. 5. Treatment- if undisplaced fx, rx with thumb spica cast (wrist in slight radial deviation).

Location of Fracture Distal Pole Waist Proximal Pole

Duration of Casting 6-8 weeks 8-12 weeks 12-24 weeks

Some authors utilize a long arm thumb spica cast initially (for about 2-6 weeks), then switch to a short arm thumb spica for the until fx line healed radiographically. If continued pain or evidence of avascular necrosis/nonunion at 12 weeks, referral to surgeon is appropriate. If displaced fx referral to surgeon for screw placement. G. Thumb fractures: 1. Bennett's fx- intra-articular fx of base (proximal end) 1st metacarpal. The abductor pollicis longus tendon pulls the shaft proximally as the deep ulnar ligament holds the small base fragment stable. Surgery (percutaneous pinning vs screw fixation) is best to maintain the anatomic reduction. Do not confuse this fx with an extra-articular fx which responds well to

7 COMMON FRACTURES: RECOGNITION AND MANAGEMENT AAFP Board Review 2006 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] nonsurgical treatment. 2. Rolando's fx- comminuted, intra-articular fx base of 1st metacarpal. Large fragments surgery may help. Small fragments require casting with early mobilization @5-10 days. It is surprising how well these fx will mold together resulting in a joint that allows adequate ROM. H. Hand Fractures: 1. Boxer's fx- fx of the neck of the 5th metacarpal with volar angulation of the head of the metatarsal. If undisplaced, angulation < 40 o, then ulnar gutter splint for 4 weeks usually suffices (4th and 5th metacarpals). Refer if large angulation, displacement, rotational deformity. With 2nd or 3rd metacarpal neck fractures, referral for angulation of > 5-10 o is standard of care. 2. Metacarpal shaft fx- 3rd, 4th and 5th common. Similar treatment options as above. Rotational deformity assessed by flexion of all fingers. With this maneuver, all fingers should point to the scaphoid. Note: metacarpal fx are a bit more unstable due to muscular pull of the lumbricals and interossei. Therefore, closer F/U with repeat xrays may be necessary (looking for delayed displacement and shortening). 3. Distal Interphalangeal Joint (DIP) Injuries a. Mallet Finger deformity- Occurs with a disruption of the extensor tendon that normally inserts into the proximal portion of distal phalanx. Mechanism = sudden forceful flexion of the finger. i. PE- lack of full extension at DIP. Pain on palpation of dorsum of the DIP. ii. Xrays- Usually normal, but may demonstrate avulsion fx. iii. Treatment- Splint X 6-8 weeks in full extension. The DIP must remain in extension throughout this initial splinting period or risk re-injury. Common splinting materials are alumifoam splints and Stack splints. If asymptomatic after 6-8 weeks, then splint with sports/gym/work for another 2-6 weeks. If continued extension lag, consider REFERRAL to discuss continued observation vs surgery. b. Jersey finger- Avulsion of the flexor digitorum profundus (FDP). Occurs with hyperextension of the DIP, such as a linebacker grasping for a running back's jersey. i. PE- lack of active flexion at the DIP. Pain on palpation of volar aspect of finger. Point of maximal tenderness may indicate site of tendon retraction.

8 COMMON FRACTURES: RECOGNITION AND MANAGEMENT AAFP Board Review 2006 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] ii. Xrays-normal, or may show avulsion fracture. iii. Treatment- Data demonstrates that early surgery (within one week) to reattach tendon achieves the best results. c. Distal phalanx fractures- Tuft and transverse fractures included in this group. Tuft fractures are crush (comminuted) fractures of the distal phalanx that are very stable and easily managed by family physicians. i. PE- Pain at tip of finger. + subungual hematoma. ii. Xrays- useful to help determine if possible open fracture. Look on lateral xray to determine if any fragment is near the nail (use hotlight if necessary). If fragment ? near nail bed, do not attempt decompression of subungual hematoma. iii. Treatment- supportive, splint with basket or alumifoam splint only to the tip of the finger. Allow mobility of PIP/DIP joints. Aspirate subungual hematoma if not open fracture. Using larger gauge needle (18-20g) use screwing motion with some downward pressure over the hematoma. Sometimes making two holes will allow flow of blood more freely. III. Lower Extremity A. Fibular fractures- note, especially with eversion injuries. · Fibular shaft fx- often secondary to direct trauma to lateral calf (ie: helmet to calf during a tackle. Treated with aircast stirrup brace vs. cast immobilization depending upon severity of injury. Return to sport by 4-8 weeks. Consider Maisonneuve's fx as below. · Distal fibular fx: many classification systems. The Weber classification is as follows. Weber A = below the mortise, B = at the mortise (joint line), C = above the joint line. Weber C fx are usually associated with syndesmotic injuries. Current data do not demonstrate improved outcome with surgery of isolated lateral malleolus fractures without significant displacement. A number of studies demonstrate good results from nonsurgical treatment of these fractures with up to 3 mm of displacement. In patients with fractures with greater than 3 mm of displacement or angulation, consider orthopedic referral. · Fibular avulsion fractures: occur with typical ankle sprain, but the anterior talofibular ligament pulls with it a tiny fragment of the distal fibula. This fragment is much smaller than the size of bone fragment associated with a Weber A fracture noted above. This injury is treated exactly like an ankle sprain with rest, ice, aircast, elevation and pain control. B. Fractures at the Base of 5th Metatarsal-

9 COMMON FRACTURES: RECOGNITION AND MANAGEMENT AAFP Board Review 2006 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] · Acute, traumatic = Jone's fx. Jone's fracture is a transverse fx ~ 1.5 cm distal to the tubercle. It extends into the 4,5intermetatarsal articulation. High rate of delayed and non-union. Treatment = short leg non-weightbearing cast immobilization. May take 6-8 weeks to heal. If continued pain at 12 weeks, refer for screw fixation. For athletes, consider screw fixation immediately, return to play with incision healing. · Avulsion fx of the 5th metatarsal- fx caused by contraction of the peroneus brevis tendon. This fx does not involve the same risk for delayed/nonunion as with the Jone's fx. This fx has an excellent prognosis for healing. Rx as for ankle sprain. May need post-op shoe (hard-soled shoe for sx support).

C. Hallux (Great Toe) Fractures Hx- Mechanism of injury usually axial force (kick or stub big toe on furniture, walls, doors, etc.) Less commonly, crush force (drop something on toe) or lateralized force on great toe. PE- decreased ROM, significant swelling, ecchymosis; + subungual hematoma. Note fractures of multiple phalanges are common- so evaluation of adjacent digits is appropriate. Rx- usually requires hard-soled shoe to reduce the amount of flexion and extension that occurs with walking. Use this splint as symptoms dictate. With some fractures "buddy-taping" will suffice. REFERRAL is recommended for patients with first-toe fracture-dislocations, displaced intraarticular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when traction is released following reduction). Referral also is recommended for children with first-toe fractures involving the physis. These injuries may require internal fixation.

COMMON FRACTURES: RECOGNITION AND MANAGEMENT AAFP Board Review 2006 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected]

REFERENCES

Birrer RB, Bordelon RL, Sammarco GJ. Ankle: don't dismiss a sprain. Patient Care. 26(4):6-28, 1992. Caldwell GL, Safran MR. Elbow problems in the athlete. Ortho Clinics North Am. 26(3): 465-85, 1995. Fick DS, Lyons TA. Interpreting elbow radiology in children. Am Fam Phys. 55(4):1278-81, 1997. Gutierrez G. Office management of scaphoid fractures. Phys and Sports Med. 24(8):60-70, 1996. Hoffman DF, Schaffer TC. Management of common finger injuries. AFP. 43(5):1594-1607, 1991. Housner JA, Kuhn JE. Clavicle fractures. Phys Sports Med. 31(12): 235-244, 2003. John SD, Wherry K, Swischuk LE, et al. Improving the Detection of Pediatric Elbow Fractures by Understanding Their Mechanics. Radiographics. 1996;16(6):1443-1460. Jupiter JB. Current concepts review fractures of the distal end of the radius. JBJS. 73A(3):461-9, 1991. Kirsch LB, Herscovici D. Proximal humerus fractures. J Ortho Trauma. 15(2):146-8, 2001.

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Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med. 11(1):203-25, 1992. Mellion MB, Walsh WM, Shelton GL. The team physician's handbook. 2nd edition.Mosby, Phila, PA, 1996. Morgan RL, Linder MM. Common wrist injuries. AFP. 55(3): 857-68, 1997. Nirschl RP, Kraushaar BS. The assessment and treatment of elbow injuries. Phys Sports Med. 24(5):321-6, 1996. Rogers LF, Malave, Jr., S, White H, et al. Plastic Bowing, Torus, and Greenstick Supracondylar Fractures of the Humerus: Radiographic Clues to Obscure Fractures of the Elbow in Children. Radiology.128:145-150, 1978 Rubin A, Sallis R. Evaluation and diagnosis of ankle injuries. AFP. 54(5):1609-18, 1996. Schaffer TC. Common hand fractures in family practice. Arch Fam Med. 3:982-87, 1994. Skaggs D, Pershad J. Pediatric Elbow Trauma. Pediatr Emerg Care. 1997;13(6):425-434. Skaggs DL, Mirzayan R. The Posterior Fat Pad Sign in Association with Occult Fracture of the Elbow in Children. J.Bone and Joint Surg. 1999;81-A(10):1429-1433. Tandeter HB, Shvartzman P. Acute ankle injuries- clinical decision rules for radiographs. AFP. 55(8): 2721-8, 1997. Wilkins KE. Changes in the management of Monteggia fractures. J Ped Ortho. 22:548-54, 2002.

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