1. Common Fractures Family Medicine Resident School Lecture 4/5/17
Ashley Crum, MD
Emergency Medicine/Sports Medicine Fellow

2. objectives Identify common fractures in upper and lower extremities
Treatment
Urgent vs Non-urgent referal

3. 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

4. Middle 3rd clavicle fractures

5. Clavicle Fractures –(Middle 3rd most common)
4% of all fractures
Mechanism:
direct blow to lateral aspect of shoulder
fall on an outstretched arm or direct trauma
Exam:
Deformity present with decreased ROM
Imaging:
X-rays
CT (to better characterize fracture or vascular structures

6. Clavicle fracture management
Sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at weeks
Non-displaced middle third
Most pediatric
Stable lateral third
Operative
Open
Non-union symptomatic
Skin tenting
Vascular injury
Unstable fractures (posterior medial third, most lateral third
Ortho referral: Non-emergent for most

7. Proximal humerus fractures

8. 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
What is the most common nerve injury and why?

9. Proximal Humerus Fracture management
Sling immobilization followed by progressive rehab at 14 days
minimally displaced surgical neck fracture
greater tuberosity fracture displaced < 5mm
Surgical management
Greater tuberosity fracture displaced >5mm
Displaced surgical neck fractures
Compacted fractures with good bone quality
Ortho referral:
Urgent follow up (may call to review x-ray with)
Emergent if vascular compromise

10. Humeral Shaft fracture

11. 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

12. Humeral Shaft fracture management
Coaptation splint followed by functional brace
Most fractures, depending on displacement
2-10% risk of non-union
Surgical
Open fracture
Vascular injury
Neurological injury
Ortho referral: non-urgent in most cases

13. Distal humerus fractures (Supracondylar)

14. 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?)

15. Supracondylnar fracture management
Gartland Classification
Long arm posterior splint then long arm casting with less than 90° of elbow flexion
Type 1 and some type 2
Operative
Neuro/vascular compromise
Severe swelling
Floating elbow
Brachialis sign
Ortho referral: usually urgent or emergent

16. Other distal humerus fractures
Lateral epicondyle fracture
Medial epicondyle fracture

17. Radial head fractures

18. 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?

19. 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

20. Essex-Lopresti lesion
 Comprised of a comminuted fracture of radial head
+dislocation of the DRUJ
+interosseous membrane disruption
The DRUJ injury may be missed leading to permanent wrist pain and stiffness.

21. Galeazzi fracture Dislocation

22. Galeazzi fracture Dislocation
Definition
distal 1/3 radius shaft fx AND
associated distal radioulnar joint (DRUJ) injury
Mechanism
direct wrist trauma dorsolateral aspect
fall onto outstretched hand with forearm in pronation
Exam
Tenderness at fracture site
Check pronation/supination for instability
Stress to DRUJ causes wrist or midline pain
Imaging
X-ray forearm, elbow, wrist

23. Galeazzi management Ortho referral
Is Operative
Better outcomes with sooner rather than later surgery
Ortho referral
Would call for recommendations at time of presentation

24. Distal Radius Fractures

25. 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 ground
Exam
Deformity, neurovascular
Imaging
X-rays

26. Distal Radius fracture management
Closed 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 instability
Ortho Referral: need close follow up after reduction and splint. May need them to help you with a reduction

27. Olecranon fracture

28. Olecranon fractures Bimodal distribution Mechanism Exam Imaging
direct blow: comminuted fracture
fall onto outstretched upper extremity
transverse or oblique fracture
Exam
Check extensor mechanism
Deformity of posterior elbow
Imaging
X-ray (need a true lateral)

29. 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)

30. Monteggia fracture dislocation

31. Monteggia fracture dislocation
Proximal 1/3 ulnar fracture with associated radial head dislocation/instability
More common in children (4-10 years old)
Mechanism: FOOSH
Exam
May not be obvious, check skin integrity
ROM loss with dislocation
What nerve could be affected?
Imaging
X-ray elbow, forearm, wrist

32. Monteggia management Ortho Referral:
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

33. Ulnar and radial shaft fractures

34. 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 fractures
Surgical: radial fractures, displaced ulnar fractures
Ortho Referral: Urgent if surgical or outpatient if non-displaced

35. Scaphoid fractures

36. 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?
Imaging
X-ray: can get scaphoid view
Bone scan and MRI more sensitive

37. Scaphoid fracture management
Thumb spica cast immobilization
Stable, non-displaced fractues
Surgical
Displaced fractures
Ortho referral: close outpatient follow up

38. Lunate/perilunate dislocation

39. 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 deviated
Exam
Pain and deformity of wrist
Median nerve symptoms in 25% of patients
Imaging
X-rays

40. Lunate/perilunate dislocation management
Always needs surgery
Emergent reduction prior to surgery can be done
Ortho referral: Urgent/Emergent

41. Bennet Fracture

42. 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 1st metacarpal
Imaging
X-rays

43. Bennet Fracture Management
Closed reduction & cast immobilization: non-displaced
Surgical: displaced
Ortho Referral: Urgent follow up
Epibasal thumb fracture

44. Boxers fracture

45. Boxers fracture Ortho referral: close follow up for cast
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

46. Mallet (baseball) Finger

47. Mallet (baseball) Finger
Deformity 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 weeks
Ortho Referral: non-urgent outpatient

48. Jersey Finger

49. Jersey finger Ortho Referral: Needs urgent follow up
Avulsion 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-ray
Management: Surgical, can splint prior to surgery (<3 weeks)
Ortho Referral: Needs urgent follow up

50. Femoral neck fractures

51. 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 deformity
Imaging: x-ray (MRI for occult)
Management:
Non-operative if not ambulatory prior to fracture
Operative otherwise
Ortho referral: Emergent if surgical

52. Patella fractures

53. Patella fractures Ortho Referral: Urgent follow up
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

54. Pilon fracture (Tibial Plafond Fx)
Incidence increasing as survival rates after motor vehicle collisions increase
Mechanism: high energy axial load
(motor vehicle accidents, falls from height)
75% have associated fibula fractures
Management:
Non-operative: minimal displacement
Surgical: Most fractures
Ortho referral: Emergent

55. Maisonneuve fracture

56. Maisonneuve fracture Ortho Referral: Urgent/Emergent 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 most
Ortho Referral: Urgent/Emergent

57. Lateral malleolus fracture types

58. 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)

59. Talar Neck fractures Ortho referral: Emergent Imaging: Treatment:
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

60. 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

61. 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 Gissane
CT is gold standard
MRI: for stress fractures

62. 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 weeks
All others are operative
Subtalar arthritis increased with non-operative management

63. Jones fracture

64. 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 fixation
Prolonged immobiliazation and non-weightbearing

65. Dancer’s Fracture Avulsion fracture at base of 5th metatarsal
Ankle inversion injury
Conservative treatment if non-displaced
WBAT

66. Lis Franc

67. 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%

68. Lis franc Diagnostic clues Always consider compartment syndrome
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 injury
Treatment:
Cast for 8 weeks if non-displaced and no fracture
Surgery for most others

69. Questions

70. 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-emergent
Olecranon: non-emergent
Monteggia: emergent
Ulnar/radial shaft: urgent
Scaphoid: non-emergent
Lunate: emergent
Benett: 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

71. references
Orthobullets.com
Radiopaedia.org
Wheelesonline.com