USC Case # 13: Managing simple fractures
Case 1
CC: A 14 year old male presents with left forearm pain after falling during a pick up
basketball game two days ago.
HPI: Your patient fell forward onto his left hand. He had immediate pain focused over
the forearm 5cm from the wrist. There is only mild swelling over the area - almost
unnoticeable.
Questions
1) What are the first steps in caring for this patient?
2) What are good ways to provide comfort to this patient?
Answers
1) Good communication and providing patient comfort in a non-life threatening injury
should always be the first step. Patients with potential fractures will be anxious. Listen
to them when they express this. My experience has been that if you take a few minutes
up front rather than rushing through the visit and just ordering xrays, both you and the
patient will have a much more positive experience.
2) Most fractures with pain and swelling respond well to icing. There is currently a
debate about the use of nonsteroidal anti-inflammatory (NSAID) medication with
musculoskeletal injuries. These medications provide good pain relief but some studies
have shown that they interfere with the healing process of bones, tendons, ligaments and
their interfaces. Some physicians are moving away from using these medications and
providing other forms of pain control such as acetaminophen and/or short-term narcotic
medication. Other adjunct therapies such as aggressive icing, compression, venous and
lymphatic drainage techniques, elevation and early range of motion training after initial
healing are also important to include, but require more work on the patient's part.
The patient history
A good history should always be taken for any ailment, including fractures.
Questions
1) What are the important historical questions with regard to fracture care?
2) What specific questions are important in suspected pediatric fractures?
3) What is a major concern with crush injuries involving the extremities?
Answers
1) Go through your fracture history the same way each time so that you don't leave
anything out. You will see many examples of how to (and how not to) do this through
your training.
a) Find out the exact mechanism of the injury. In this case the patient
"Fell
Onto an OutStretched Hand", known as a "FOOSH" injury (you will see this written in
charts many times). Fractured carpal bones (especially scaphoid) are common, along
with distal radial and ulnar fractures. Knowing the activity at the time of injury along
with the
nature of the injury will help you diagnose the ailment.
b) Find out when it happened (some patients wait days or weeks
evaluated)
c) Have there been any previous injury to this area?
- This is important during examination if you pick up old
or see old fractures on xrays.
before they get
fracture sites
d) Is there any numbness or tingling over or around the area? Where
exactly
is the pain now? These facts can sometimes help indicate neurovascular injury or
compromise.
e) What was the magnitude of the force?
f) What was the direction of the involved force?
2) In the case of pediatrics, ask the parents how the child has been behaving. This can
give a clue as to where the injury may be and how severe it is. Because the young patient
cannot give as thorough a history it is important to look for nonverbal cues such as
posturing, obvious asymmetry, bruising patterns, neurologic status, etc. All of the above
questions are important as well and should be directed to the parents.
3) Any time there is a blunt injury, especially with regard to the lower leg and forearm,
you must evaluate the patient for a potential compartment syndrome. These sometimes
accompany a fracture. The mechanism is a blood vessel is ruptured from the trauma and
subsequently bleeds in the fascial covering of a muscle. Fascia only stretches to a certain
point. The problem arises when the blood outflow from the muscle cannot keep up with
the internal bleeding, causing swelling, ischemia and pain and sometimes compromise of
blood flow to distal structures.
The 5 "P's" of compartment syndrome are:
Pain - from swelling and ischemia
Pallor - of distal structures
Pulselessness - distal to the injury
Paresthesias - from nerve compression within the swollen
compartment
Paralysis - From neurovascular compromise (more of an end-stage
sign)
Examining the area
Questions
1) What are the important steps to examining a suspected fracture?
2) What is the difference between an open and closed fracture?
Answers
1) Start as you would with any other ailment:
a) Inspect
- look for swelling, bruising, skin damage, obvious asymmetry or
gross angulation of body parts
- check for symmetry with the unaffected extremity
b) Palpate around the injury, saving the painful part of the exam for
last
c) Examine the joint above and joint below for concomitant injuries
d) Check neurovascular status - pulses, capillary refill time and
sensation
e) Check range of motion and strength
- Again, using the unaffected side can help you identify
pathology. Some parts of the exam will likely be too painful
to perform.
2) Open or closed fractures are classified by whether the skin overlying a fracture is
intact.
- Any puncture or break in the overlying skin is considered and open fracture until
proven otherwise. Open fractures require that you evaluate for the need for antibiotic
coverage and tetanus prophylaxis.
- If there is a crush injury to the extremity or the nail is avulsed or severely
compromised, the fracture will be classified open and should be treated as such, including
antibiotic and tetanus therapy.
Taking an xray
Questions
1) What kind of imaging is most appropriate for an initial evaluation?
2) What are the best views to order for a standard xray?
Answers
1) Always start with plain xrays. There is a growing trend to go
to CT or MRI. Don't fall into this habit during an initial
evaluation.
immediately
2) Essentially you want at least two views of the area in question so that you can see the
fracture from two angles (usually ordered as "AP (anterior-posterior) and lateral"). Some
fractures may not be visible on one view, but stand out dramatically from a different
angle. Each area of the body has specific views which can help you diagnose the
problem and you will learn these during your clinical years. More views may be helpful,
but the specifics of these are beyond the scope of this introduction.
Naming fractures
Questions
1) What are the steps to naming a fracture?
Answers
1) Learning to name a fracture well sounds easier than it is. The steps involved are:
a) Name the side involved
b) Name the involved bone
- In this case, radius and ulna
c) Name the type of fracture
- Angulated or nonangulated
- in this case - nonangulated
- Displaced or nondisplaced
- in this case - nondisplaced,
d) State where on the bone the fracture is
- eg. 5cm from distal radius and ulna
e) There are many other descriptors that can be used in fracture
nomenclature that you will learn as you advance in your training.
Being able to communicate the type of fracture you see to your attending physician will
be a good skill to have as a student and resident.
Here is an example of a right distal radial fracture that is nondisplaced and nonangulated.
Caring for a fracture
Questions
1) What are the steps in caring for a fracture?
2) What are the basic steps in applying a cast?
Answers
1) A fracture needs to be immobilized to prevent displacement and promote healing.
However, the first few days of a fracture can produce more swelling than is seen initially.
Because of this, casting should be postponed until the initial swelling has resolved. A
good option at this point is called the Robert Jones dressing. This provides stability and,
at the same time, room for the injured site to swell. It involves two pieces of plaster or
orthoglass (one on either side of the injury), a good deal of padding (usually cotton wrap)
all wrapped in an ace bandage. The patient can then be brought back in 2-3 days and the
area re-inspected. This is the time to apply a cast. There are also many other braces that
are over the counter or custom that can be used for this initial inflammatory phase.
2) Casting is a skill unto itself. Indeed there are individuals who do nothing but cast
patients all day in large practices. Others do only a few a year. You will see all types
and qualities of casts through your training. Do your best to gain experience and become
as skilled as you can with cast application. A quality cast will provide the patient a good
healing environment and be comfortable for them to wear.
- The basic steps of cast application are:
1) Clean and dry the area to be casted. Make sure you have inspected
for potential infection before you apply a cast.
2) Cover the area with a cast sock (tubular stocking that can be
cut to desired length).
3) Wrap the area with padding*.
4) Cover the area with cast material (this is almost always
fiberglass pre-packaged material ranging from 1" to 4"). It is
from the package, applied and then wetted down to
people opt to wet it first, but remember the
material begins to cure the moment it is wetted down.
Fold the extra padding and cast sock under the ends of the
material for patient comfort and also to make the cast
professional.
5) Recheck your work. This is very important. Check for any
fiberglass areas that are rubbing directly on the skin. Always
patient if anything is pinching them or if they would
altered. Again, this is just good patient care.
removed
cure it. Some
cast
look
ask the
like the cast
* Padding is usually a cotton based material, but some patients opt for Gore-Tex material
that can be immersed in water safely during the life of the cast. This is a nice option but
almost no insurance company will pay for this (they consider it "cosmetic" and thus,
unnecessary). Patients who want this are required to cover its cost in most practices,
usually around $50.
Complications
- If your patient is intoxicated, unconscious or has an underlying psychiatric disorder,
obtaining a good history may not be possible. This is also the case with young children,
when you must rely mainly on parental histories. Keep this in mind during an H&P.
Your index of suspicion for fractures must be higher with these patients, especially after
traumatic injuries that place the patient in this altered state of consciousness.
- No matter how good you are, eventually one of your casts will not work well. Always
review with patients the reasons to contact you, especially things such as numbness,
tingling or pallor of areas distal to the cast. The can indicate a potential compartment
syndrome or a cast that is simply too tight.
- Remember to always leave to door open for patients to contact you with questions or
concerns. This will head off most small problems before they become larger.
General notes
- Do not refer all fractures to an orthopedic surgeon. This happens reflexively all too
often. Simple fractures can be easily and confidently managed in the primary care office.
Remember, if you refer everything that walks into your office to specialists (orthopedics,
dermatology, neurology, etc), your patients will eventually find a doctor who is more
confident in their skills. That being said, some fractures do demand a surgeon's opinion.
You will learn these as you go through your training.
- Always remember to follow up with your patients and document everything that was
done at a visit. Providing quality medical literature and fracture care handouts can also
help your patient a great deal.
References
1) McRae, R, Esser, M. Practical Fracture Treatment. 4th Ed. Churchill
Livingstone, Harcourt Press, 2002.