1. Fracture Management for Primary Care Physicians
Thomas Berkbigler, DO, PT
Orthopedic Surgeon

2. Disclosures
None that I am aware of that will bias this talk

3. Why are we discussing this?
Orthopedic problems are over 10% of all primary care visits
1.6% of all visits to any physician are fracture related
16% of all fracture care is handled by family physicians

4. Objectives Identify common fractures in Primary Care
Proper use of a splint versus a cast
Identify commonly used casting materials and when to use them
Demonstrate proper cast application and removal
Describe appropriate patient education with regards to casting
Understand general fracture principles, when to refer out fracture care
Understand management of specific fractures
Recognize osteoporotic fractures

5. General Principles Two (2) Principle Questions What to Refer?
How to stabilize
What to Manage on my own?
How to treat what I keep

6. Casting - Overview Mainstay of treatment for most fractures
Joint above and a joint below
Avoid pressure points
Proper molding
Cast indentations
Appropriate padding
More at bony prominence
Not too much at fracture site
Consider skin wounds

8. Splinting - Overview Purpose What to splint Reduce pain
Reduce bleeding and swelling
Prevent further soft tissue damage
Prevent vascular constriction
What to splint
Fracture
Dislocation
Tendon rupture

10. Supplies Stockinette Padding material Cast material
Plaster: cheaper, long shelf life, easier to work with
May be fragile, disintegrate in water
Fiberglass: more durable, lighter, dry quicker, multiple colors, water tolerant
Newer synthetic materials

12. Procedure Apply stockinette Apply padding Wet the casting material
Protect skin and provide smooth edge
Apply padding
Protect bony prominence
Allows for swelling
Wet the casting material
Hot water hardens faster
Squeeze out excess water
Apply splint or cast

13. Patient Instructions Keep injured limb elevated and iced Warning signs
Numb extremity - Inability to move extremity
Discoloration, Cold - Increased pain
Avoid getting wet
Completely with plaster
May use hair dryer on cool setting if fiberglass
Anti-histamines

14. Splint Types Upper Extremity: Lower Extremity:
Wrist Cock-up -Sugar-tong
Ulnar Gutter -Radial Gutter
Long arm Splint -Coaptation
Lower Extremity:
Posterior Ankle slab -Stir-ups
Long leg splint

15. Take Home Points You will see fractures
Know your comfort level and when to refer
Splint acutely and with active swelling
Variety of materials
Know what you have, be comfortable with it
Educate your patients

16. Fractures

17. General Principles Two (2) Principle Questions What to Refer?
How to stabilize
What to Manage on my own?
How to treat what I keep

18. OLD ACIDS Mnemonic O: open or closed L: location D: degree
A: articular involvement
C: comminution/type
I: instrinsic bone quality
D: displacement
S: soft tissue injury

21. Metatarsal / Phalanges
Keep
Minimally/Non-displaced fractures
Short leg cast
NWB 4-8 weeks
Refer
Lis Franc fracture or Jones Fracture
Displaced Metatarsal Shaft or intra-articular fractures
Multiple fractures
Short leg splint; NWB

24. Ankle Fractures Keep: Avulsion fractures and some Weber A type
Some Weber B fractures
Need stress radiograph
Splint : posterior slab +/- stirrups x1 week
Cast: Short leg x2-6 weeks
NWB 2-8 weeks
AROM ~4 weeks
PT for ankle strengthening and proprioceptive training

26. Ankle Fractures Refer: Bi/Trimalleolar Fractures
Bimalleolar Equivalency Fractures
Talar subluxation
Articular impaction
Syndesmosis dysruption
Treatment: Reduce and Splint (Posterior slab with stirrups)
Significant Joint involvement – Obtain post-reduction CT

28. Clavicle Fractures Keep Refer
Shaft type with minimal displacement and shortening
Sling or Figure 8 for 4-6 weeks
ROM/Strengthening thereafter
Refer
Comminution, shortening, distal/proximal type
Sling

30. Proximal Humerus Fracture
Neer Classification
Helps determine treatment
1-Part
2-Part
3-Part
4-Part

31. Proximal Humerus Majority need close follow up with Orthopedics
Even if non-displaced initially may displace later or present with later stage rotator cuff issues.
Sling or Sling and Swathe
Osteoporotic Fracture

33. Distal Radius
Most common orthopaedic injury with a bimodal distribution
younger patients - high energy
Elderly patients – low energy fall (OP)
Manage?
Non-displaced extra-articular
Well reduced extra-articular with good bone quality in a well-molded cast/splint

34. Distal Radius Fractures
Die-punch
Barton's
Chauffer's
Colles'
Smith's
A depressed fracture of the lunate fossa of the articular surface of the distal radius
Fx dislocation of radiocarpal joint with intra-articular fx involving the volar or dorsal lip (volar Barton or dorsal Barton)
Radial styloid fx
Low energy, dorsally displaced, extra-articular
Low energy, volar displaced, extra-articular fx

35. Take home point…understand the energy

38. Surgical Options

40. How to treat? Options: Splint and refer? Splint and cast later?
Reduce and splint?
Cast and manage?
Reduce and Cast?

41. Scaphoid Fractures
Scaphoid is most frequently fractured carpal bone; 15% of wrist injuries
Prognosis
incidence of AVN with fracture location
Proximal 1/5 = 100% Proximal 1/3 = 33%
Wrist pain after fall
Splint vs. Cast 2 weeks
Repeat xrays – no fx, continued snuff box pain and pain with pronation = MRI
Refer out – thumb spica splint or cast

43. Oops…
If texting an image…please include the whole xray

44. Osteoporosis
By Definition: Fall from standing resulting in Proximal Humerus, Distal Radius, Hip fracture, Spine compression fracture
CBC, CMP, T4, TSH, Vit D3 level
Bisphosphonate?
Forteo?
Drug class: Parathyroid Hormone Analog

45. In the acute presentation Highly swollen extremity Compromised Skin
Question #1: In General, when should a splint be applied to a fracture, in lieu of a cast?
In the acute presentation
Highly swollen extremity
Compromised Skin
None of the above
All of the above

46. #1 Answer
5. All of the above

47. Question #2:
Which Fracture when obtained in an adult from a simple fall does not meet criteria for Osteoporosis?
Femoral Neck Fracture
Scaphoid Fracture
Hip Intertrochanteric Fracture
L2 Compression Fracture
Distal Radius Colles Fracture
Comminuted 4-Part Proximal Humerus Fracture

48. #2 Answer
2. Scaphoid

49. Question #3:
Which Metatarsal Fracture is easily treated by a Primary Care Physician?
Jones Fracture
Fifth (5th) Metatarsal Avulsion fx
Lis Franc Fracture
Marching Fractures
Widening of the 1st Inter-metatarsal web space

50. #3 Answer
2. Fifth (5th) Metatarsal Avulsion fx

51. Question #4:
What are some complications with elderly distal radius “Colles” fractures?
Continued fracture collapse
Carpal Tunnel Syndrome
Skin Tears – from fall or from reduction
Loss of ROM
Profound dexterity achievement after cast immobilization

52. #4 Answer 4. Profound dexterity achievement after cast immobilization
i.e. If you had poor piano skills before…

53. Question #5:
Which Clavicle is a good candidate for non-operative management? A B C D

54. A B C D

55. #5 Answer C

56. References
Eiff MP, et al. Fracture management for Primary Care, 2nd edition. Saunders
Honsik K, et al. Sideline splinting, bracing and casting of extremity injuries. Current sports Medicine Reports ;2:
Meredith RM, et al. Field splinting of suspected fractures: preparation, assessment, and application. The Phys and Sports Med ;25(10).

57. Calcaneus and Talus Keep None Short leg splint; NWB
Complicated – High long-term pain rate
Typically Higher energy fractures

59. Tibia Shaft Fractures Keep Very few
Most - Long leg splint and refer
Minimal allowance for mal-alignment: trend is to stabilize surgically for early ROM
Exceptions:
Toddler’s Fracture
Obtain phone consult of Orthopedist
Elderly/Non-ambulatory – minimally displaced
Well padded Long leg cast

61. Femur Shaft Fractures
Non-operative: only in the baseline non-ambulatory or severely unhealthy
Non-displaced: NWB 8-12 weeks
Displaced: NWB essentially lifelong
Operative:
ORIF via Plate and screw construct versus IM Nail

63. Hip Fractures – Femoral Neck
Non-operative: only in the baseline non-ambulatory or severely unhealthy
Non-displaced: NWB 8-12 weeks
Displaced: NWB essentially lifelong
Operative:
Closed reduction and perc screws; Hemi versus Total Hip Arthroplasty

65. Hip Fracture - Intertrochanteric
Non-operative: only in the baseline non-ambulatory or severely unhealthy
Non-displaced: NWB 8-12 weeks
Displaced: NWB essentially lifelong
Operative:
Intramedullary Nail Device versus DHS type device

67. Humeral Shaft Fracture
Complex Fractures
Acceptable limits: <30° Anterior; <20° Var/val; <3cm shortening
Associated with radial nerve palsy
Refer most out
Coaptation splint +/- long arm splint
Definitive treatment: varied, Hanging arm cast, Sarmiento, ORIF, IM Nail

70. Fractures About the Elbow
Refer: Supracondylar, Intercondylar, Olecranon, intra-articular, displaced, elbow dislocation
If elbow dislocation, reduce, long arm splint
Radial Head/Neck Fx
isolated minimally displaced (less than 2mm) fxs with no mechanical blocks
Long arm splint x3-7 days, then early ROM
Consider aspiration

72. Mason Classification
Type I Minimally displaced fx, no mechanical block to rotation, intra-articular displacement <2mm
Type II Displaced fx >2mm or angulated, possible mechanical block to forearm rotation
Type III Comminuted and displaced fx, mechanical block to motion
Type IV (Hotchkiss modification)Radial head fx with elbow dislocation