Fracture Management
for Primary Care
Physicians
Thomas Berkbigler, DO, PT
Orthopedic Surgeon
Disclosures
None that I am aware of that will bias this
talk
Why are we discussing this?
Orthopedic problems are over 10% of all
primary care visits
1.6% of all visits to any physician are
fracture related
16% of all fracture care is handled by
family physicians
Objectives
1.
2.
3.
4.
5.
6.
7.
8.
Identify common fractures in Primary Care
Proper use of a splint versus a cast
Identify commonly used casting materials and when to
use them
Demonstrate proper cast application and removal
Describe appropriate patient education with regards to
casting
Understand general fracture principles, when to refer
out fracture care
Understand management of specific fractures
Recognize osteoporotic fractures
General Principles
Two (2) Principle Questions
1. What to Refer?
 How to stabilize
2. What to Manage on my own?
 How to treat what I keep
Casting - Overview
Mainstay of treatment for most fractures
Joint above and a joint below
Avoid pressure points


Proper molding
Cast indentations
Appropriate padding


More at bony prominence
Not too much at fracture site
Consider skin wounds
Splinting - Overview
Purpose
Reduce pain
Reduce bleeding and swelling
Prevent further soft tissue damage
Prevent vascular constriction
What to splint
Fracture
Dislocation
Tendon rupture
Supplies
Stockinette
Padding material
Cast material

Plaster: cheaper, long shelf life, easier to
work with
May be fragile, disintegrate in water


Fiberglass: more durable, lighter, dry quicker,
multiple colors, water tolerant
Newer synthetic materials
Procedure
Apply stockinette

Protect skin and provide smooth edge
Apply padding


Protect bony prominence
Allows for swelling
Wet the casting material


Hot water hardens faster
Squeeze out excess water
Apply splint or cast
Patient Instructions
Keep injured limb elevated and iced
Warning signs


Numb extremity - Inability to move extremity
Discoloration, Cold
- Increased pain
Avoid getting wet


Completely with plaster
May use hair dryer on cool setting if fiberglass
Anti-histamines
Splint Types
Upper Extremity:



Wrist Cock-up
Ulnar Gutter
Long arm Splint
-Sugar-tong
-Radial Gutter
-Coaptation
Lower Extremity:


Posterior Ankle slab
Long leg splint
-Stir-ups
Take Home Points
You will see fractures
Know your comfort level and when to refer
Splint acutely and with active swelling
Variety of materials

Know what you have, be comfortable with it
Educate your patients
Fractures
General Principles
Two (2) Principle Questions
1. What to Refer?
1. How to stabilize
2. What to Manage on my own?
 How to treat what I keep
OLD ACIDS
Mnemonic
O: open or closed
L: location
D: degree
A: articular involvement
C: comminution/type
I: instrinsic bone quality
D: displacement
S: soft tissue injury
Metatarsal / Phalanges
 Keep
1.
2.
3.
Minimally/Non-displaced fractures
Short leg cast
NWB 4-8 weeks
 Refer
1.
2.
3.
4.
Lis Franc fracture or Jones Fracture
Displaced Metatarsal Shaft or intra-articular
fractures
Multiple fractures
Short leg splint; NWB
Ankle Fractures
Keep:


Avulsion fractures and some Weber A type
Some Weber B fractures
Need stress radiograph





Splint : posterior slab +/- stirrups x1 week
Cast: Short leg x2-6 weeks
NWB 2-8 weeks
AROM ~4 weeks
PT for ankle strengthening and proprioceptive training
Ankle Fractures
Refer:







Bi/Trimalleolar Fractures
Bimalleolar Equivalency Fractures
Talar subluxation
Articular impaction
Syndesmosis dysruption
Treatment: Reduce and Splint (Posterior slab with
stirrups)
Significant Joint involvement – Obtain post-reduction
CT
Clavicle Fractures
Keep



Shaft type with minimal displacement and
shortening
Sling or Figure 8 for 4-6 weeks
ROM/Strengthening thereafter
Refer


Comminution, shortening, distal/proximal type
Sling
Proximal Humerus Fracture
Neer Classification

1.
2.
3.
4.
Helps determine
treatment
1-Part
2-Part
3-Part
4-Part
Proximal Humerus
Majority need close follow up with
Orthopedics
Even if non-displaced initially may displace
later or present with later stage rotator cuff
issues.
Sling or Sling and Swathe
Osteoporotic Fracture
•
Distal Radius
Most common orthopaedic injury with a
bimodal distribution


younger patients - high energy
Elderly patients – low energy fall (OP)
Manage?


Non-displaced extra-articular
Well reduced extra-articular with good bone
quality in a well-molded cast/splint
Distal Radius Fractures
Barton's
A depressed fracture of the
lunate fossa of the articular
surface of the distal radius
Fx dislocation of radiocarpal
joint with intra-articular fx
involving the volar or dorsal lip
(volar Barton or dorsal Barton)
Chauffer's
Radial styloid fx
Die-punch
Colles'
Smith's
Low energy, dorsally
displaced, extra-articular
Low energy, volar displaced,
extra-articular fx
Take home point…understand the
energy
Surgical Options
How to treat?
Options:





Splint and refer?
Splint and cast later?
Reduce and splint?
Cast and manage?
Reduce and Cast?
Scaphoid Fractures
Scaphoid is most frequently fractured carpal
bone; 15% of wrist injuries
Prognosis

incidence of AVN with fracture location
Proximal 1/5 = 100%
Proximal 1/3 = 33%
Wrist pain after fall


Splint vs. Cast 2 weeks
Repeat xrays – no fx, continued snuff box pain and
pain with pronation = MRI
Refer out – thumb spica splint or cast
Oops…
If texting an
image…please
include the
whole xray
Osteoporosis
By Definition: Fall from standing resulting
in Proximal Humerus, Distal Radius, Hip
fracture, Spine compression fracture
CBC, CMP, T4, TSH, Vit D3 level
Bisphosphonate?
Forteo?

Drug class: Parathyroid Hormone Analog
Question #1: In General, when should a splint be
applied to a fracture, in lieu of a cast?
1.
2.
3.
4.
5.
In the acute presentation
Highly swollen extremity
Compromised Skin
None of the above
All of the above
#1 Answer
5. All of the above
Question #2:
1.
2.
3.
4.
5.
6.
Which Fracture when obtained in an adult from
a simple fall does not meet criteria for
Osteoporosis?
Femoral Neck Fracture
Scaphoid Fracture
Hip Intertrochanteric Fracture
L2 Compression Fracture
Distal Radius Colles Fracture
Comminuted 4-Part Proximal Humerus
Fracture
#2 Answer
2. Scaphoid
Question #3:
1.
2.
3.
4.
5.
Which Metatarsal Fracture is easily
treated by a Primary Care Physician?
Jones Fracture
Fifth (5th) Metatarsal Avulsion fx
Lis Franc Fracture
Marching Fractures
Widening of the 1st Inter-metatarsal web
space
#3 Answer
2. Fifth (5th) Metatarsal Avulsion fx
Question #4:
1.
2.
3.
4.
5.
What are some complications with
elderly distal radius “Colles” fractures?
Continued fracture collapse
Carpal Tunnel Syndrome
Skin Tears – from fall or from reduction
Loss of ROM
Profound dexterity achievement after
cast immobilization
#4 Answer
4. Profound dexterity achievement after cast
immobilization
i.e. If you had poor piano skills before…
Question #5:
Which Clavicle is a good candidate for
non-operative management?
A
B
C
D
A
B
C
D
#5 Answer
C
References
Eiff MP, et al. Fracture management for Primary
Care, 2nd edition. Saunders. 2003.
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).
Calcaneus and Talus
Keep




None
Short leg splint; NWB
Complicated – High long-term pain rate
Typically Higher energy fractures
Tibia Shaft Fractures
Keep

Very few
Most - Long leg splint and refer


Minimal allowance for mal-alignment: trend is
to stabilize surgically for early ROM
Exceptions:
Toddler’s Fracture

Obtain phone consult of Orthopedist
Elderly/Non-ambulatory – minimally displaced

Well padded Long leg cast
Femur Shaft Fractures
Non-operative: only in the baseline nonambulatory or severely unhealthy


Non-displaced: NWB 8-12 weeks
Displaced: NWB essentially lifelong
Operative:

ORIF via Plate and screw construct versus IM
Nail
Hip Fractures – Femoral Neck
Non-operative: only in the baseline nonambulatory or severely unhealthy


Non-displaced: NWB 8-12 weeks
Displaced: NWB essentially lifelong
Operative:

Closed reduction and perc screws; Hemi
versus Total Hip Arthroplasty
Hip Fracture - Intertrochanteric
Non-operative: only in the baseline nonambulatory or severely unhealthy


Non-displaced: NWB 8-12 weeks
Displaced: NWB essentially lifelong
Operative:

Intramedullary Nail Device versus DHS type
device
•
Humeral Shaft Fracture
Complex Fractures


Acceptable limits: <30° Anterior; <20° Var/val;
<3cm shortening
Associated with radial nerve palsy
Refer most out

Coaptation splint +/- long arm splint
Definitive treatment: varied, Hanging arm
cast, Sarmiento, ORIF, IM Nail
Fractures About the Elbow
Refer: Supracondylar, Intercondylar, Olecranon,
intra-articular, displaced, elbow dislocation

If elbow dislocation, reduce, long arm splint
Radial Head/Neck Fx



isolated minimally displaced (less than 2mm) fxs with
no mechanical blocks
Long arm splint x3-7 days, then early ROM
Consider aspiration
Mason Classification
Type I Minimally displaced fx,
no mechanical block to
rotation, intra-articular
displacement <2mm
Type II Displaced fx >2mm or
angulated, possible
mechanical block to forearm
rotation
Type III Comminuted and
displaced fx, mechanical block
to motion
Type IV (Hotchkiss
modification)Radial head fx
with elbow dislocation