basic care of common fractures - ucsf medical education · transverse, oblique, spiral, comminuted,...

Basic Care of Common Basic Care of Common FracturesFractures

Utku Kandemir, MDUtku Kandemir, MDAssistant Clinical ProfessorAssistant Clinical ProfessorTrauma & Sports MedicineTrauma & Sports Medicine

Dept. of Orthopaedic SurgeryDept. of Orthopaedic SurgeryUCSF / SFGHUCSF / SFGH

HistoryHistoryPhysical ExamPhysical ExamRadiologyRadiologyTreatmentTreatment

HistoryHistory

Acute trauma vs. repetitive trauma vs. no traumaAcute trauma vs. repetitive trauma vs. no traumaMechanism of InjuryMechanism of Injury

Direct vs. Indirect ForceDirect vs. Indirect ForceHigh energy vs. Low energyHigh energy vs. Low energy

Past Medical & Surgical HistoryPast Medical & Surgical HistoryStress Stress fxfx, Occult , Occult fxfx, , osteopeniaosteopenia/osteoporosis, RA, Steroid /osteoporosis, RA, Steroid useuse

Physical ExaminationPhysical Examination

InspectionInspectionDeformity, swelling, Deformity, swelling, ecchymosisecchymosis, open wound, open wound

Active ROMActive ROMPalpation / Passive ROMPalpation / Passive ROMNeurovascular ExaminationNeurovascular Examination

Compartment syndrome: 8 hrs

Compartment Syndrome Compartment Syndrome --DefinitionDefinition

IncreasedIncreased pressure within an pressure within an osseofascialosseofascialcompartment compartment reducing reducing perfusion gradient across tissue perfusion gradient across tissue capillary beds capillary beds leading toleading to cellular anoxia and death cellular anoxia and death (muscles & nerves)(muscles & nerves)

Compartment Syndrome Compartment Syndrome --EtiologyEtiologyFractureFractureSoft tissue injurySoft tissue injuryBleeding disordersBleeding disordersTight cast, dressing, external wrappingTight cast, dressing, external wrappingArterial injuryArterial injuryBurnBurnLongLong--lasting limb compression (drug overdose etc.)lasting limb compression (drug overdose etc.)ExtravasationExtravasation of intravenous infusionof intravenous infusionReperfusion injuryReperfusion injuryPenetrating traumaPenetrating trauma

Compartment Syndrome Compartment Syndrome --DiagnosisDiagnosis

Clinical Clinical +/+/-- Compartment pressure measurementsCompartment pressure measurementsSwellingSwellingTense/Firm compartmentTense/Firm compartmentPain out of proportion regarding severity of the injuryPain out of proportion regarding severity of the injuryPain aggravated with passive stretchPain aggravated with passive stretch

NeurologicNeurologic deficit deficit Sensory (hypoesthesia, Sensory (hypoesthesia, paraesthesiaparaesthesia ) ) Motor (paresis, paralysisMotor (paresis, paralysis

Compartment Syndrome Compartment Syndrome --TreatmentTreatment

Emergency Emergency FasciotomiesFasciotomies

RadiologyRadiology

XX--ray Orderray Order

Include the joint above and belowInclude the joint above and belowNo less than 2 views: AP & LateralNo less than 2 views: AP & LateralComparative views in skeletally immatureComparative views in skeletally immature

RadiologyRadiology

Reading xReading x--raysraysLocation of fracture (1/3)Location of fracture (1/3)

Proximal, Middle, Distal Proximal, Middle, Distal IntraIntra-- vs. Extra vs. Extra articulararticular

Displacement Displacement AngulationAngulation, Translation, Shortening, Distraction, Rotation, Translation, Shortening, Distraction, Rotation

Pattern Pattern Transverse, Oblique, Spiral, Comminuted, SegmentalTransverse, Oblique, Spiral, Comminuted, Segmental

PediatricPediatricTorusTorus/buckle, Greenstick, /buckle, Greenstick, PhysealPhyseal

RadiologyRadiologyLocation of fracture (1/3)Location of fracture (1/3)

Proximal, Middle, Distal Proximal, Middle, Distal

Proximal 1/3

Middle 1/3

Distal 1/3

Proximal 1/3 Middle 1/3 Junction

Middle 1/3 Distal 1/3 Junction

RadiologyRadiologyLocation of fractureLocation of fracture

IntraIntra-- vs. Extra vs. Extra articulararticular

RadiologyRadiologyAngulationAngulation: :

degrees APEX degrees APEX anterior/posterior, anterior/posterior, medial/lateralmedial/lateral

Medial Lateral

RadiologyRadiologyShortening / Overlap, DistractionShortening / Overlap, Distraction

RadiologyRadiologyTranslationTranslation

12

RadiologyRadiologyRotationRotation

RadiologyRadiologyIntraarticularIntraarticular displacement: gap, stepdisplacement: gap, step--offoff

RadiologyRadiologyPediatricPediatric

PhysealPhyseal, , TorusTorus/buckle, Greenstick /buckle, Greenstick

Fractures vs. DislocationsFractures vs. Dislocations

Reduction of Dislocation is NECESSARY acutelyReduction of Dislocation is NECESSARY acutelyFracture dislocations needs to be seen by Orthopaedics Fracture dislocations needs to be seen by Orthopaedics urgentlyurgentlyFractures may be splinted as far as Fractures may be splinted as far as neurovascularlyneurovascularlyintact, grossly aligned, no risk of further soft tissue intact, grossly aligned, no risk of further soft tissue injury injury

Dislocation: no contact of Dislocation: no contact of articulararticular surfacessurfaces

Initial TreatmentInitial Treatment

When in doubt about fractureWhen in doubt about fractureImmobilizeImmobilizeInform the patient about the possibility of a fracture Inform the patient about the possibility of a fracture ((nondisplacednondisplaced fxsfxs, some fractures may not be apparent , some fractures may not be apparent up to 2 weeks e.g. up to 2 weeks e.g. scaphoidscaphoid))Arrange follow up with an Arrange follow up with an orthopaedicorthopaedic surgeonsurgeon

Initial TreatmentInitial Treatment

Immobilization (splinting, bracing)Immobilization (splinting, bracing)Rest (NWB)Rest (NWB)Cold (Ice packs)Cold (Ice packs)

Limits hemorrhage and edema, increases pain thresholdLimits hemorrhage and edema, increases pain threshold1515--20 min q4hrs (20 min q4hrs (frosbitefrosbite injury!)injury!)

ElevationElevationPain controlPain control

Splinting/BracingSplinting/Bracing

Immobilization of fracture, sprain, soft tissue injuryImmobilization of fracture, sprain, soft tissue injuryPrevent further soft tissue injury (neurovascular, Prevent further soft tissue injury (neurovascular, musculotendinousmusculotendinous, skin), skin)Pain controlPain controlReduction of edemaReduction of edemaMaintains bony alignmentMaintains bony alignment


Plaster of Paris or FiberglassPlaster of Paris or Fiberglass

Advantage over casting: Allows continued swellingAdvantage over casting: Allows continued swellingavoid complication: compartment syndromeavoid complication: compartment syndrome


Remove all clothing and constrictive devices from extremity (jewelry, rings)Align severely angulated fracture

alleviates acute pain, relieves blood vessel and nerve tension, and may restore circulation to a pulseless extremity

Apply padding (cotton), Protect bony prominencesAssess neurovascular status immediately before and after splinting and DOCUMENTIf periodic wound care is required / relatively stable fracture consider a removable splint

Emergency / UrgencyEmergency / Urgency

UnreduceableUnreduceable dislocationdislocationNeurovascular deficit (before OR after Neurovascular deficit (before OR after reduction/splinting)reduction/splinting)Open fracture/ Impending open fractureOpen fracture/ Impending open fracture

Risk Management Risk Management

Always document neurovascular status before and aftersplint application, fracture or joint reductionRemove all rings on hands/toes before splint applicationClearly document follow-up instructions:

with whomwhen to see orthopedic surgeonwhen to return to the emergency department

Clavicle FractureClavicle FractureArm sling / Clavicle Arm sling / Clavicle supportsupportUrgentUrgent

OpenOpenNeurovascular injuryNeurovascular injuryTenting skin (impending Tenting skin (impending open)open)

Proximal Proximal HumerusHumerus FracturesFractures

APAP, , AxillaryAxillary view, Y viewview, Y view

Proximal Proximal HumerusHumerus FracturesFracturesAP, AP, AxillaryAxillary viewview, Y view, Y view

Confirm that the GH joint is reduced or notConfirm that the GH joint is reduced or not


AP, AP, AxillaryAxillary viewview, Y view, Y viewConfirm that the GH joint is reducedConfirm that the GH joint is reduced


AP, AP, AxillaryAxillary view, view, Y viewY view


Neurovascular exam: Neurovascular exam: AxillaryAxillary nerve nerve (dermatome: proximal 1/3 (dermatome: proximal 1/3 lateral arm)lateral arm)Brachial plexusBrachial plexus


Acute care: Acute care: Shoulder immobilizerShoulder immobilizerArm slingArm sling

HumerusHumerus Shaft FracturesShaft Fractures

MidshaftMidshaft: Radial Nerve : Radial Nerve !!

Definitive treatmentDefinitive treatmentMostly Mostly nonoperativenonoperative

HumerusHumerus Shaft FracturesShaft Fractures

Acute Care: Arm sugar tong splint /Shoulder immobilizerAcute Care: Arm sugar tong splint /Shoulder immobilizer

Elbow (Distal Elbow (Distal HumerusHumerus, , OlecranonOlecranon))Make sure that the joint is not dislocatedMake sure that the joint is not dislocatedLong arm splint at 45 degreesLong arm splint at 45 degreesDefinitive treatment Definitive treatment

Mostly surgicalMostly surgical

Radial Head FracturesRadial Head FracturesTenderness at lateral elbow , pain with Tenderness at lateral elbow , pain with pronation/supinationpronation/supination,,Check Wrist (DRUJ)Check Wrist (DRUJ)Long arm splint at 90 degreesLong arm splint at 90 degrees

Forearm fracturesForearm fractures

Compartment syndromeCompartment syndromeLong Arm SplintLong Arm Splint

Definitive treatment Definitive treatment Surgery in adults, >10 yrs oldSurgery in adults, >10 yrs old

Distal Radius FracturesDistal Radius FracturesShort arm / Sugar tong splintShort arm / Sugar tong splint

Leave MCP joints mobileLeave MCP joints mobile

ELEVATIONELEVATION

ScaphoidScaphoid fracturesfractures

Snuffbox tendernessSnuffbox tendernessFracture may not be visible Fracture may not be visible first couple weeksfirst couple weeksThumb splint/ thumb gutter Thumb splint/ thumb gutter splintsplint

Metacarpal fracturesMetacarpal fractures

Short Arm Splint extending to the tip of fingersShort Arm Splint extending to the tip of fingers

UlnarUlnar Gutter for 5Gutter for 5thth MC neck MC neck fxfx

Finger fracturesFinger fractures

NailbedNailbed hematomahematomaAluminum splint &/ taping to the next fingerAluminum splint &/ taping to the next finger

Metatarsal FracturesMetatarsal Fractures

Short Leg Splint/ Lower Leg WalkerShort Leg Splint/ Lower Leg Walker

Ankle FractureAnkle Fracture

AP, Lateral, Mortise viewsAP, Lateral, Mortise viewsMake sure the joint is reduced after reductionMake sure the joint is reduced after reductionShort leg splint / Lower leg walkerShort leg splint / Lower leg walker

Ankle FractureAnkle Fracture

Tibia Plateau FractureTibia Plateau Fracture

Swollen kneeSwollen knee ROMROM

Acute Acute TxTx: : NWBNWBKnee immobilizerKnee immobilizer

Patella FracturePatella Fracture

Swollen kneeSwollen kneeLoss of active extensionLoss of active extension

Thank youThank you

[email protected]@orthosurg.ucsf.edu

www.orthotrauma.comwww.orthotrauma.com

Phone: (415) 206Phone: (415) 206--33403340

Fax: (415) 647Fax: (415) 647--37333733

mailto:[email protected]://www.orthotrauma.com/

Basic Care of Common FracturesHistoryPhysical ExaminationCompartment Syndrome -DefinitionCompartment Syndrome -EtiologyCompartment Syndrome -DiagnosisCompartment Syndrome -TreatmentRadiologyRadiologyRadiologyRadiologyRadiologyRadiologyRadiologyRadiologyRadiologyRadiologyFractures vs. DislocationsInitial TreatmentInitial TreatmentSplinting/BracingSplinting/BracingSplinting/BracingEmergency / UrgencyRisk Management Clavicle FractureProximal Humerus FracturesProximal Humerus FracturesProximal Humerus FracturesProximal Humerus FracturesProximal Humerus FracturesProximal Humerus FracturesHumerus Shaft FracturesHumerus Shaft FracturesElbow (Distal Humerus, Olecranon)Radial Head FracturesForearm fracturesDistal Radius FracturesScaphoid fracturesMetacarpal fracturesFinger fracturesMetatarsal FracturesAnkle FractureAnkle FractureTibia Plateau FracturePatella FractureThank you

basic care of common fractures - ucsf medical education · transverse, oblique, spiral, comminuted,...

Documents