1. Management of Extremity Fractures
Bucky Boaz, ARNP-C

2. 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

3. Metacarpal Fractures Second most common fracture in primary care
Classified according to location:
Head
Neck
Shaft
Base

4. 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

5. 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

6. 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

7. Metacarpal Fractures Management Ulnar Gutter Splint Splint: Reduction:
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

8. 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

9. Fracture 4th metacarpal
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

10. Wrist Anatomy Metacarpals and phalanges Trapezium Carples
Scaphoid (navicular)
Distal radius
Lunate
Triquetrium
Pisiform
Capitate
Hamate
Trapezoid

11. Wrist Anatomy Dorsal Anatomic Landmarks Radial styloid
Extensor pollicis brevis
Anatomic snuffbox
Extensor pollicis longus
Lister’s tubercle
Dorsal wrist depression
Ulnar styloid

12. Wrist Anatomy Radial styloid Scaphoid tubercle Carpal tunnel Hamulus
Volar anatomic landmarks
Radial styloid
Scaphoid tubercle
Carpal tunnel
Hamulus
Pisiform

13. 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

14. Scaphoid Fracture Patients will complain of wrist pain Swelling
Particularly over anatomic snuff box
Swelling
Motion is commonly limited

15. Scaphoid Fracture Radiographs need to include scaphoid view
Elongates the scaphoid along its long axis
At least 10%-20% false negative on x-ray

16. 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

17. 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)

18. Scaphoid Fracture Management
Immobilize even if x-rays negative if warranted
Immobilization with thumb spica
Ortho referral

19. 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

20. 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

21. Colles’ Fracture
Definitive care may be provided by primary care provider
Reduction of fracture
Splinting
Ortho referral
Inter-articular fracture needs ortho follow up

22. 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

23. 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

24. 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

25. 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

26. Monteggia’s Fracture Radiographic: Ulnar fracture
Dislocation of radial head
High index of suspension required

27. 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

28. Radial Head Fracture Radiographic: AP and lat Fat pad may be only clue
(occurs as a result of distension of the capsule by an intra-articular hemarthrosis)
Large sail shape abnormal
Posterior abnormal

29. 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

30. 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

31. Distal Humeral Fracture
Described as:
Supracondylar
Transcondylar
Intercondylar
Hyperextension of elbow during FOOSH
AP and lat views sufficient

32. 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

33. 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

34. 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

35. 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

36. Clavicle Fracture Radiographic: Treatment:
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)

37. 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

38. 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 x-rays

39. 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)

40. Fractures of Tibial Shaft
Radiologic:
Cross-table lat and AP
Immobilize prior to x-rays if obvious fracture
Analgesia
Assessment of knee and ankle
                                     

41. Fractures of Tibial Shaft
Immobilization
Long or medium posterior splint with application of stirrups
Elevation and ice
Immediate ortho referral

42. 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

43. 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

44. 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

45. 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

46. Ankle Fractures Most common lower-extremity fracture
15% of patients examined for ankle injury will have a fracture
Successful management requires determination of stable vs unstable

47. 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

48. 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 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

49. Ankle Fractures Three bones make up the ankle joint:
Distal tibia
Distal fibula
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

50. 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

51. Ankle Fractures Radiographic: AP, lat, and mortise views
Mortise view consists of:
Medial clear space
Tibular/fibular clear space
Tibular/fibular overlap
Lateral clear space

52. 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

53. 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

54. Ankle Fractures Treatment: Ortho referral 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

55. 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

56. Fractures of the Fifth Metatarsal
Types of fifth metatarsal fractures:
Avulsion fracture
Jones fracture (Metaphyseal- diaphyseal junction)
Apophysis

57. 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

58. Questions?