Fractures:  A Primary Care Guide

Author:  Dr. Neil Dilworth CCFP (Feb 27, 2012 with BJSM update June 6, 2016)

Overview:  General practitioners (GPs) provide the assessment and management of greater than 10% of all fractures (#’s).⁴   The aim of this fracture guide is to assist GPs with fracture description as well as assessment and management of stable #’s.

Definie :  Bone Anatomy

Epiphysis – the articular end of a bone,
Physis – growth plate
Metaphysis – the broadening of bone between the shaft and growth plate
Diaphysis – shaft of long bone.
Stable Fractures – less likely to deviate from treatment course
Unstable Fractures – likely to displace during treatment.

Fracture Location
Intraarticular – fracture crosses into joint space
Extraarticular – fracture spares the joint space.
Proximal third, middle third, distal third if fracture on diaphysis.

Fracture Type
Transverse – fracture line lies horizontally across bone
Spiral – results from a rotational/torquing force
Oblique – angle of fracture oblique to axis of bone
Comminuted – fracture involves multiple pieces of same bone
Displacement – Movement of distal segment of bone along transverse fracture line deviating from axial alignment
Angulation – distal segment of fractured bone is angled away from proximal bone axis
Rotation – distal bone of fracture is twisted from original axis
Impaction – Distal bone segment is forced into proximal segment causing shortening and overlapping of bone.
Open (compound) fractures – where bone is communicating with broken skin barrier, even if not direct, these fractures require antibiotic coverage and referred to orthopedics.

Pediatric fractures
Greenstick – bending of bone with break in one side of cortex
Torus fracture –  Also known as a buckle fracture, compression of bone causing a circumferential swelling of bone and failure of cortex
Salter Harris Classification*:
I – straight across physis, nondisplaced
II – straight across physis and involving metaphysic
III – straight across and involving epiphysis
IV – through metaphysic, physis and epiphysis
V – crush injury of the physis

Ottawa Knee Rules⁹ for imaging:  Ottawa Knee rules:  Over age 55, pain over patella, proximal fibula, unable to flex knee to 90 degrees, unable to weight bear

Ottawa Ankle/foot Xray rules⁸ for imaging:  Unable to weight bear, pain over post med malleolus, pain over post lateral malleolus, pain over base of 5^th MT, pain over navicular bone

History:  Allergies, Medications, Past History, Last meal and events leading to injury, hand dominance and pre-injury function.  Ask patient to point to area of maximal pain.

Examination:  Look for swelling, deformity, eccymosis, redness, broken skin, hemorrhage, wounds that may communicate with bone.  A neurovascular examination should be included for all suspected fracture patients including 2 point discrimination <0.5cm in hands.  Then patient should be asked if they can move the joint or affected area by themselves to assess AROM.  If not obvious, gentle palpation if necessary prior to imaging for deformity, tenderness otherwise xrays may be ordered.  Place patient in slab immobilisation prior to xray

Diagnostic Imaging:  Rule of 2’s 2 views (AP, Lateral +/- extra (ie. Oblique, Skyline, axillary, weight bearing)), 2 joints – joint above and below, 2 times – pre and post reduction.  View on high resolution screen, systematically view all tissue and bone on each film for abnormalities.

Fracture management :  Immobilisation, elevation, ice.

Analgesia:  Immobilisation, tylenol 1g po q6h prn, Toradol 30-60mg IM (30mg IV), opiate options – morphine 10mg IM/IV, oxycontin 5mg i-ii tabs q4h prn pain⁶
Pediatric – tylenol 15-30mg/kg, Morphine 0.1mg/kg IM/IV ¹¹
Immobilisation – sling, slab, cast
Casting^1,4,5:  Immobilize affected joint, get patient in position, measure stockingette and cast/slab length, apply stockingette, followed by cast padding, apply extra padding over boney prominences, then apply plaster/fibreglass cast or slab, position patient’s affected appendage in desired position.  Check neurovascular before and after.
Therapy:  Range of motion and strengthening of affected joint after immobilisation.

Fracture Healing:

5 phases of bone healing 1) Inflammatory phase (1 week) 2) Granulation (~2 weeks) 3) Callus formation (4-16 weeks) 4) Lamellar bone deposition 5) Remodelling  (stage 4+5 ~1-4 years)³

Recovery time of patients with acute nonoperative #’s – range from ~ 4-6 weeks, with the exception of scaphoid which take up to 8 weeks, and distal radial/ulnar fractures which take up to 7 weeks.⁴

Educate patients about compartment syndrome.

When to refer to orthopedics:  Neurovascular compromise, Intraarticular fractures, open fractures, comminuted fractures, unstable fractures, prolonged pain and/or dysfunction despite “normal” imaging.

Complications:

Arthritis – post traumatic
Avascular Necrosis – AVN
Compartment syndrome – common with casting, pain out of proportion with injury.
Deep vein thrombosis – DVT
Delayed union
Non-uniion
Osteomyelitis
Vascular injury (pain out of proportion with injury)

Common Fractures

Clavicle  ^{4, 10}

Description: 5 – 10% of fractures.  Pain w/ shoulder movement, downward, inward deformity of shoulder.  Include in assessment NV exam and respiratory symptoms check and examination.
Diagnostic Imaging: AP, cephalic 45^o tilt
Management:  Sling – 4 to 8 weeks until nontender
Referral:  Ortho: If symptomatic non-union after 12-16 weeks, if pediatric and/or displaced and coracoclavicular ligamentous tear
F/U:  at 1-2 weeks then q2-3 weeks prn, with repeat Xray at 6 weeks⁴

Scapula^1,4,5

Description:  Pain, tenderness, ecchymosis. a) coracoid b)Glenoid (boney bankart lesion)  c) glenoid neck d) body e) spine
Diagnostic Imaging:  AP, axillary, true scapular lateral (Y)
Management:  Sling for comfort, symptom control, early ROM exercises as pain permits.
Referral:  Ortho:  a) displaced coracoid fractures b) If>25% of glenoid displaced, or recurrent instability  c) displaced glenoid neck fracture
F/U:  1-2 weeks⁴, need xray showing healing prior to starting resistance exercises

Humerus^1,4,5

Description:  Patient supporting affected arm, deformity, pain tenderness, ecchymosis
a) Anatomical neck b)Greater tuberosity c) Surgical neck d)Lesser tuberosity e) various combinations of above f) Midshaft Fracture
Diagnostic Imaging:  AP with internal and external or trauma series (AP, transcapular, axillary)
Management:  Collar and cuff
Referral:  Ortho: Fracture-dislocation, displaced 2-4 part fractures, NV damage (radial in midshaft), distortion of bicipital groove, AVN associated with anatomical neck fractures.
F/U: q2weeks with xrays until union healing⁴

Radial/Ulnar^1,4,5

Description:  Colles Fracture – dorsal displacement of radius from wrist joint.  Fall on outstretched hand (FOOSH), Common in women middle-age to elderly.  Osteoporosis is a risk factor.
Smith’s Fracture – volar displacement of radius from wrist joint
Diagnostic Imaging:  AP/Lat
Management:  Colles – double sugar tong splint⁴, with wrist in flexion and ulnar deviation
Referral:  Unacceptable reductions, intraarticular involvement, NV damage (median), comminuted fracture, loss of reduction in first 3 weeks⁵
F/U:  Non displaced 3-5 days, displaced 2-3 days⁴

Scaphoid^{1,4,5, 12} 

Description:  FOOSH or kickback injury.  Snuffbox tenderness, dorsal and volar tenderness over scaphoid.
5-25% of scaphoid #s are non-union¹², proximal pole receives retrograde blood supply.  50% of #’s occur through waist, 38% in proximal half, 12% in distal half.⁵  Concern regarding AVN of proximal scaphoid if inappropriately treated.
Diagnostic Imaging:  Scaphoid xrays – 3 views^1,4,5
Management:  Thumb Spica X 12 weeks¹²
Referral:   Nondisplaced fractures of proximal scaphoid, displaced fractures, non-union, early signs of AVN
F/U:  Re-xray at 2 weeks.  If fracture, continue with thumb spica and F/U at 6 weeks.  If no fracture but symptomatic repeat xray biweekly until diagnosis or asymptomatic  Also consider MRI or CT. ^4,5  If no fracture, and asymptomatic remove cast.⁴

Metacarpal Fracture: ^2,4,5,7

Description:  Also known as a boxer’s fracture, usually of 4^th or 5^thmetacarpal neck. Account for 30-50% of all hand fractures.⁷  Assess for rotation by having patient flex MCP, PIP joints fully with DIP joints in extension, overlapping of fingers suggests malrotation at MC.
Diagnostic Imaging:  Xray
Management:^2,,5,7   Basic principles.  Splint should involve wrist at 20-30 deg ext, with MCPs at 90 deg, buddy tape affected digits to prevent malrotation during healing.  Splint for 3 weeks.⁷
ROM and strengthening exercises after immobilisation.
Referral:   Angulated fractures of 2^nd or 3^rd MC, malrotation, malunion, angulation >40deg. ⁴
F/U:  7-10days with repeat xray^2,4 assessing for malrotation and angulation

Patellar Fracture: ^2,4,5

Description:  Occur secondary to dashboard injuries or direct fall onto knee.  Swelling over patella, with pain.  Assess for patient ability to extend affected knee to rule out quadriceps tear. 50-80% are horizontal fractures. ²
Diagnostic Imaging:  Use Ottawa knee rules⁹.  AP, lat, sunrise. ^2,4
Management: Immobilise lower limb with knee in full extension 3-6 weeks.^2,4,5
Referral:  If patient requires quadriceps repair, displaced patellar fractures, comminuted patellar fractures
F/U:  5-7 days, weekly xrays for first 2-3 weeks^2,5,  Return to activity after therapy 8-10 weeks.⁴

Ankle: ^1,4,5

Description:  Use Ottawa Ankle rules⁸, classificiations Danis-Weber’s, Lauge-Hansen, and Potts.  Fractures can involve lateral malleolus, posterior malleolus, medial malleoulus.  The following information is for stable isolated malleolar or distal fibular shaft fractures. % Weber’s
Diagnostic Imaging:   AP/Lat/mortise view (AP with 15 deg of adduction), and proximal tib/fiba to R/O maissoneuve fracture ^1,4,5
Management:  U slab initially with foot in 90 degrees dorsiflexion. Then cast/Aircast walking boot with foot in 90 degrees dorsiflexion for 6-8 weeks, compression, ice 20-30 min q 2-4 hours, elevation.  NWB with crutches. ROM exercises after immobilisation. ^1,4,5
Referral:  If Unstable (unilateral with ligament disruption on contrallateral side, bimalleolar, trimalleolar fractures), unsatisfactory reduction, disruption of the mortise.
F/U:  3-5 days for casting,  2 weeks re: symptoms, 4 weeks for xray check for union, if no union remain in immobilisation with xray q2weeks ⁴

Practical pearls:  Immobilisation, elevation and icing may be used prior to imaging to decrease patient’s discomfort.  Avoid common pitfalls by assessing neurovascular status prior to and post management.  Be aware of limits to radiological investigations, and have a high index of suspicion if patient still symptomatic despite “normal” Xrays.   When the history provides an inadequate mechanisms of injury to account for extent of injury consider abuse and bone tumours.  And finally if pain and dysfunction are not in keeping with injury also consider neurovascular injury, compartment syndrome or multiple injuries.

Fracture epidemiology in male elite football players from 2001 to 2013: ‘How long will this fracture keep me out?’

References and Resources:

1.  Birrer RB, Kalb RL Field Guide to Fracture ManagementLippincott Williams & Wilkins

1st Ed. 2009.

2.  Bracker MD The 5-minute sports medicine consult  Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins, c2011. 2nd ed.

3.  Buckley R; Panaro CDA, Calhoun JH General Principles of Fracture Care  emedicine Medscape Jan 15, 2010.  http://emedicine.medscape.com/article/1270717-overview#a0112

4.  Eiff MP; Hatch RL; Calmbach WL; Higgins MK  Fracture management for primary care Philadelphia : Saunders, c2003. 2^nded.

5.  McRae R  Pocketbook of Orthopedics and Fractures  Elsevier, 2006. 2^nd ed.

6.  Nudo C and Russ A Canadian Drug Pocket: Clinical Reference Guide.  Borm Bruckmeier Publishing LLC, El Segundo, California, 2008.  4^th ed.

7.  O’Gorman A, Ashwood N  Managing metacarpal fractures  Trauma, ISSN 1460-4086, 10/2006, Volume 8, Issue 4, pp. 249 – 260

8.  Ottawa Ankle Rules:  http://www.ohri.ca/emerg/cdr/ankle.html

9.  Ottawa Knee Rules:  http://www.ohri.ca/emerg/cdr/knee.html

10.  Pecci M, Kreher JB. Clavicle Fractures American Family Physician77. 1 (Jan 1, 2008): 65-70.

11.  Pediatric fracture guidelines – http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5206

12.  Tysver T, Jawa A Fractures in brief: scaphoid fractures  Clinical orthopaedics and related research, ISSN 0009-921X, 09/2010, Volume 468, Issue 9, p. 2553

13.  Larsson D, Ekstrand J, Karlsson M Fracture epidemiology in male elite football players from 2001 to 2013: ‘How long will this fracture keep me out?’ Br J Sports Med 2016;50:759-763 doi:10.1136/bjsports-2015-095838