1. Fracture Care and Casting for Primary Care Physicians Matt Leiszler, MD Stephanie Chu, DO Jack Spittler, MD University of Colorado Sports Medicine

2. Goal Provide an intro to fracture management and casting for family physicians

3. Objectives Identify common fractures in Primary Care Identify common fractures in Primary Care Proper use of a splint versus a cast Proper use of a splint versus a cast Identify commonly used casting materials and when to use them Identify commonly used casting materials and when to use them Demonstrate proper cast application and removal Demonstrate proper cast application and removal Describe appropriate patient education with regards to casting Describe appropriate patient education with regards to casting

4. Introduction Orthopedic problems are over 10% of all primary care visits Orthopedic problems are over 10% of all primary care visits 1.6% of all visits to any physician are fracture related 1.6% of all visits to any physician are fracture related 16% of all fracture care is handled by family physicians 16% of all fracture care is handled by family physicians

5. Fractures seen by FPs FractureEiffHatchAlcoff Finger 17%18%12% Metacarpal 1675 Radius 141016 Toe 991 Fibula 777 Metatarsal 654 Clavicle 567

6. Fractures seen by FPs 4 th digit distal phalanx fracture 4 th and 5 th metacarpal fracture Distal radius fracture

7. Fractures seen by FPs Other Fractures: Radius and ulna Radius and ulna Carpal Carpal Ulna Ulna Humerus Humerus Tibia Tibia Tarsal Tarsal

8. Casting and Splinting

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

10. Splinting

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

12. Specific splints Forearm and wrist – –Ulnar gutter Metacarpal – –Thumb spica Scaphoid Ankle – –Posterior splint – –“L and U” or Sugartong

13. Casting Jones Fracture

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

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

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

17. Patient Education Keep cast clean Keep cast clean Do not stick objects into cast Do not stick objects into cast Do not pull out the padding Do not pull out the padding Watch for skin irritation Watch for skin irritation Do not modify your cast Do not modify your cast Watch for cracking and breaking of cast Watch for cracking and breaking of cast

18. Cast Removal Cast saw Vibrates, doesn’t rotate Biggest concern is burn

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

20. Recommended Resources Eiff MP, et al. Fracture management for Primary Care, 2 nd edition. Saunders. 2003. Eiff MP, et al. Fracture management for Primary Care, 2 nd edition. Saunders. 2003. Honsik K, et al. Sideline splinting, bracing and casting of extremity injuries. Current sports Medicine Reports. 2003;2:147-154. Honsik K, et al. Sideline splinting, bracing and casting of extremity injuries. Current sports Medicine Reports. 2003;2:147-154. Meredith RM, et al. Field splinting of suspected fractures: preparation, assessment, and application. The Phys and Sports Med. 1997;25(10). Meredith RM, et al. Field splinting of suspected fractures: preparation, assessment, and application. The Phys and Sports Med. 1997;25(10).