fracture management: breaks for the fp to fix · 1 fracture management: breaks for the fp to fix...
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Fracture Management: Breaks for the FP to Fix
Deepak Patel, MD, FAAFP, FACSM
ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.
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DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.
All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.
The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.
Deepak Patel, MD, FAAFP, FACSMDirector of Sports Medicine, Rush Copley Family Medicine Residency Program, Aurora, Illinois; Assistant Professor, Rush Medical College, Chicago, Illinois
A past FMX presenter, Dr. Patel practices family medicine and sports medicine in Aurora and Yorkville, Illinois, and is medical director for Rush Copley Sports Medicine. His specialty topics include musculoskeletal imaging, concussions, stress fractures, osteoarthritis, joint examinations, pediatric overuse injuries, knee pain, tendonitis/tendonopathy, fractures, and exercise recommendations, as well as evidence-based medicine. He is a fellow of the American College of Sports Medicine. Since Dr. Patel also practices family medicine, he is able to deliver effective presentations to help family physicians address sports medicine and musculoskeletal complaints. He serves as chair for the 2019 AAFP Musculoskeletal and Sports Care course. Dr. Patel has found that staying current with medical advances and evidence-based medicine is the most challenging aspect of family medicine.
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Learning Objectives1. Identify patients at high risk of fracture, and establish preventive care
measures.
2. Assess injured bones or soft tissue to determine the stage and severity of the injury and the most effective mechanism of treatment.
3. Evaluate appropriate imaging modalities for patients with fractures that require diagnostic imaging evaluation.
4. Determine appropriate indications for fracture immobilization, providing adequate pain control as necessary.
5. Coordinate patient education, monitoring and follow-up care.
Associated Sessions
• (PBL) Fracture Management: Breaks for the FP to Fix
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Audience Engagement SystemStep 1 Step 2 Step 3
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Overview
Fractures
Diagnostic Imaging
Clavicle
5th
Metacarpal
Scaphoid
AnkleMetatarsal
Pediatric Ankle
Pediatric Radius (buckle)
Pain control
Fracture Diagnosis‐Imaging
• X‐ray preferred
• 3 views preferred (AP, LAT oblique)
• Fracture lucency seen on >1 view
• MRI an option if uncertain
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• Computer aided software algorhythm for distal radius fracture
• Algorhythm aided providers improved sensitivity, specificity, speed of detection
Fracture Imaging‐ A.I.?
https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm608833.htm, accessed 5/31/18.
Fracture Imaging‐ Computed Tomography
• Enhanced visualization of fracture lines, loose bodies, bony comminution, position of fracture fragments (SORT:C)
• Consider for elbow anterior fat pad with normal x‐ray (SORT:C)
• Evaluate healing or not (delayed union vs non‐union) (SORT:C)
• Complex fractures (SORT:C)
Corris E, Zwygart K, Fletcher M, Pescasio M. Imaging in Sports Medicine, An Overview. Sports Med Arthrosc Rev 2009;17:2–12
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Fracture Imaging‐ Ultrasound
Fracture Type Sensitivity Specificity
Forearm 2,3 97.1% 95‐100%
Peds Forearm1,3 99.5% 99.5%
Buckle Fracture4 98.4% 95.3%
Upper Ext5 95.3% 87.7%
Lower Ext.5 98.6% 83%
1. Ko C, Baird M, Close M, Cassas KJ. The Diagnostic Accuracy of Ultrasound in Detecting Distal Radius Fractures in a Pediatric Population. Clin J Sport Med. 2017 Nov 15. doi: 10.1097/JSM.0000000000000547. [Epub ahead of print]
2. Douma-den Hamer D, et. Al. Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis. PLoS One. 2016 May 19;11(5):e0155659. doi: 10.1371/journal.pone.0155659. eCollection 2016.
3. Herren C, et. Al. Ultrasound-guided diagnosis of fractures of the distal forearm in children. Orthop Traumatol Surg Res. 2015 Jun;101(4):501-5. doi: 10.1016/j.otsr.2015.02.010. Epub 2015 Apr 21.
4. Soegtrop, R. Et. Al. Point-of-care Ultrasound for Distal Forearm Buckle Fractures in Children: Test Performance and Pain Outcomes Pediatrics Jan 2018, 141 (1 MeetingAbstract) 353; DOI: 10.1542/peds.141.1_MeetingAbstract.353
5. Frouzan A, et. Al. Diagnostic accuracy of ultrasound in upper and lower extremity long bone fractures of emergency department trauma patients. Electron Physician. 2017 Aug 1;9(8):5092-5097. doi: 10.19082/5092. eCollection 2017 Aug.
Clavicle fractures
• Fall onto shoulder with arm adducted
• 4% of all fractures.
• 76% middle‐third section
Lenza M, Faloppa F. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD007121. DOI: 10.1002/14651858.CD007121.pub4.Woltz S, Krijnen P, Schipper IB. Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Randomized Controlled Trials. J Bone Joint Surg Am. 2017 Jun 21; 99(12):1051-1057.
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Clavicle fractures‐ figure 8 vs sling
Cochrane review: figure 8 vs sling
• 3 studies (296 pts)
• Little difference in shoulder function
• 1 study more pain w/ figure 8
• Equal fracture healing, adverse events, time to return (school / work activities)
• Larger study pending
Lenza M, Faloppa F. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD007121. DOI: 10.1002/14651858.CD007121.pub4.Lenza M, Taniguchi LF, Ferretti M. Figure-of-eight bandage versus arm sling for treating middle-third clavicle fractures in adults: study protocol for a randomised controlled trial. Trials. 2016 May 4;17(1):229. doi: 10.1186/s13063-016-1355-8.
Clavicle fractures‐ Surgical Referrral
• Displacement >1 clavicle width should be plated to reduce risk of non union
• RCT (302 pts): • At 3 months: no diff. non‐union
• At 9 months: non‐union in surgical
lower (0.8%) vs (11%)
• Surgery Pt satisfaction higher
• Cochrane: insufficient data on surgical vs conservative treatment
Woltz S, Krijnen P, Schipper IB. Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Randomized Controlled Trials. J Bone Joint Surg Am. 2017 Jun 21; 99(12):1051-1057.Ahrens PM, Garlick NI, Barber J, Tims EM; Clavicle Trial Collaborative Group. The Clavicle Trial: A Multicenter Randomized Controlled Trial Comparing Operative with Nonoperative Treatment of Displaced Midshaft Clavicle Fractures. J Bone Joint Surg Am. 2017 Aug 16;99(16):1345-1354. doi: 10.2106/JBJS.16.01112. Lenza M, Faloppa F. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD007121. DOI: 10.1002/14651858.CD007121.pub4.
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Boxers Fracture
• 5th MC neck/head
• Punching hard object
• Volar displacement
Diagnosis
• Observe deformity (loss)of 5th knuckle
• Tenderness
• Assess ROM/malrotation (see picture for normal)
• X‐ray
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AES Question 1
Boxers fracture needs reduction if angulation greater than?
A.10 deg
B.25 deg
C.40 deg
D. 70 deg
Boxers fracture‐Treatment
• Ulnar gutter/gauntlet splint• Close follow up exam/x‐ray in 2 wks
• Immobilize for 4‐6 wks
• Non‐displaced‐cast 4‐6 wks, then progressive ROM/ flexibility/ strengthening
• Malrotated, displaced and/or fragmented surgical referal
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Boxers fracture‐Treatment Soft wrap?
• RCT, 68 pts,
• 5th MC neck fx < 70 deg.
• Soft wrap +buddy taping vs reduction + cast
• 4 months, no difference: pain, appearance satisfaction, MCP mobility, grip strength
• Time off 11 days less with wrap
• Sys. Rev.: wrap=reduction + cast
Van Aaken J, Fusetti C, Luchina S, Brunetti S, Beaulieu JY, Gayet-Ageron A, Hanna K, Shin AY, Hofmeister E. Fifth metacarpal neck fractures treated with soft wrap/buddy taping compared to reduction and casting: results of a prospective, multicenter, randomized trial. Arch Orthop Trauma Surg. 2016 Jan;136(1):135-42. doi: 10.1007/s00402-015-2361-0. Epub 2015 Nov 11.Dunn JC, Kusnezov N, Orr JD, Pallis M, Mitchell JS. The Boxer's Fracture: Splint Immobilization Is Not Necessary. Orthopedics. 2016 May 1;39(3):188-92. doi: 10.3928/01477447-20160315-05. Epub 2016 Mar 29.
Scaphoid fracture• Fall onto out‐stretched hand (FOOSH) injury
• Tender snuffbox sensitive (96%), not specific (39%) (SOR: A)
• Thumb compression: sensitive (82%), specific (58%) (SOR: A)
PHILLIPS, T.G., REIBACH, A.M., and SLOMIANY, W.P.; Diagnosis and Management of Scaphoid Fractures Am Fam Physician 2004;70:879-84 Shehab R, Mirabelli MH. Evaluation and diagnosis of wrist pain: a case-based approach. Am Fam Physician. 2013 Apr 15;87(8):568-73.Tait, Mark; Bracey, John; Gaston, R. Acute Scaphoid Fractures: A Critical Analysis Review. JBJS Reviews. 4(9), September 27, 2016. DOI: 10.2106/JBJS.RVW.15.00073
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AES Question 2
If you suspect scaphoid fracture with a negative initial x‐ray. The most sensitive advanced imaging is?
A.Bone Scan
B.CT
C.MRI
D.Ultrasound
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Scaphoid fracture‐ imaging
• 3 view + scaphoid (navicular view) (SOR: C)
• Imaging: x‐ray often negative initially (SOR: B)
• Bone scan = MRI (less cost‐effective) (SOR: A)
• Any suspicion: thumb spica splint, repeat exam (tenderness), imaging in 10‐14 days (SOR: C)
• ?immediate MRI/CT more cost effective (SOR:B)
PHILLIPS, T.G., REIBACH, A.M., and SLOMIANY, W.P.; Diagnosis and Management of Scaphoid Fractures Am Fam Physician 2004;70:879-84 Shehab R, Mirabelli MH. Evaluation and diagnosis of wrist pain: a case-based approach. Am Fam Physician. 2013 Apr 15;87(8):568-73.Li, E., and Sanford, C.; What is the best imaging test for patients with suspected scaphoid fractures and normal plain radiographs? Evidence-Based Practice Vol. 20,(7) July 2017Khan MS, et al.. Evidence-based practice: best imaging practice in musculoskeletal disorders. J Trauma Nurs. 2014 Jul-Aug;21(4):170-9; quiz 180-1. doi: 10.1097/JTN.0000000000000059.
Scaphoid Fracture Imaging
Test Sensitivity Specificity
CT 72% 99%
MRI 88% 100%
Bone Scan 99% 86%
Mallee WH, Wang J, Poolman RW, Kloen P, Maas M, de Vet HCW, Doornberg JN. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD010023. DOI: 10.1002/14651858.CD010023.pub2.
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Scaphoid fracture- waist
Scaphoid Fracture‐MRI
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Scaphoid fracture‐ Treatment
• Non displaced fx:
• Short arm cast w/ or w/o Thumb spica
• Casting: 6‐12 wks
• Thumb spica stabilizes scaphoid
• longer for proximal pole vs distal pole?
• Displaced fracture needs Ortho for ORIF
Kawanishi Y, Oka K, Tanaka H, Sugamoto K, Murase T. In Vivo Scaphoid Motion During Thumb and Forearm Motion in Casts for Scaphoid Fractures. J Hand Surg Am.2017 Jun;42(6):475.e1-475.e7. doi: 10.1016/j.jhsa.2017.03.008. Epub 2017 Mar 30.Arsalan-Werner A, Sauerbier M, Mehling IM. Current concepts for the treatment of acute scaphoid fractures. Eur J Trauma Emerg Surg. 2016 Feb;42(1):3-10. doi: 10.1007/s00068-015-0587-8. Epub 2015 Nov 25.Shehab R, Mirabelli MH. Evaluation and diagnosis of wrist pain: a case-based approach. Am Fam Physician. 2013 Apr 15;87(8):568-73.Tait, Mark; Bracey, John; Gaston, R. Acute Scaphoid Fractures: A Critical Analysis Review. JBJS Reviews. 4(9), September 27, 2016. DOI: 10.2106/JBJS.RVW.15.00073
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Scaphoid non‐union
Scaphoid non‐union= OA
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Ankle
AES Question 3
In regards to the “Ottawa Ankle Rules” which of the
following is true?
A. Used for x‐ray decision making for the toe injuries
B. X‐ray required for any bone tenderness of the malleoli
C. X‐ray required for patient only able to limp 3 steps after injury
D. X‐ray required for tenderness of metatarsals
E. Not validated for use in children
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Ottawa Ankle rules
An ankle x‐ray only pain in the malleolar zone and 1 of these: (SORT: A)
• Bone tenderness at posterior edge (6 cm) or tip of lateral malleolus.
• Bone tenderness at posterior edge (6 cm) or tip of medial malleolus
• Inability to bear weight both immediately and in Emergency Department (4 steps, limping is ok)
Tiemstra, J. Update on Ankle Sprains. Am Fam Physician. 2012 Jun 15;85(12):1170-1176.Patel, D., Chinta, S., “Which ankle injury scoring system is best for reducing the need for x-rays?” Evidence Based Practice; 2010; 13(1):5-6.Beckenkamp PR, Lin CC, Macaskill P, et al. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis Br J Sports Med Published Online First: 24 November 2016. doi: 10.1136/bjsports-2016-096858
Ottawa Ankle rules
• reduce the need for X‐rays by 24‐29%,
• when neg, fracture can be ruled out 99% of the time (SOR: A)
Tiemstra, J. Update on Ankle Sprains. Am Fam Physician. 2012 Jun 15;85(12):1170-1176.Patel, D., Chinta, S., “Which ankle injury scoring system is best for reducing the need for x-rays?” Evidence Based Practice; 2010; 13(1):5-6.Beckenkamp PR, Lin CC, Macaskill P, et al. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis Br J Sports Med Published Online First: 24 November 2016. doi: 10.1136/bjsports-2016-096858
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Lateral malleolus avulsion fractures
• Similar MOA as ankle sprain
• Crutches as needed
• Can be treated with ankle stirrup
• Return to sport/activity with bracing in 3‐4 wks
Ankle fractures
•212 pts Weber B distal fibular fracture
•RCT ankle stirup, vs 6 wks casting, vs 3 wks casting
•No difference in healing•2 non‐union in 3 wks cast
Kortekangas Tero, Haapasalo Heidi, Flinkkilä Tapio, Ohtonen Pasi, Nortunen Simo, Laine Heikki-Jussi et al. Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority li i l i l BMJ 2019 364 k5432
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Foot Fractures
Ottawa Foot Rules
A foot x‐ray if any: (SORT: A)• Bone tenderness at based of the 5th MT
• Bone tenderness at Navicular
• Inability to bear weight both immediately and in Emergency Department (4 steps, limping is ok)
• Sens: 99.1%
• Spec: 43.4%Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 2003;326:417.Beckenkamp PR, Lin CC, Macaskill P, et al. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis Br J Sports Med Published Online First: 24 November 2016. doi: 10.1136/bjsports-2016-096858
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Ottawa Foot/ Ankle Rules: 44‐55‐66PM
• 4 steps immediately
• 4 steps in office/ED
• 5th MT
• 5caphoid
• 6 cm Med Post Malleolus
• 6 cm Lat Post Malleolus
AES Question 4
The metatarsal fracture with the highest risk of non‐union is?
A.2nd metatarsal neck
B.5th metatarsal shaft
C.5th metatarsal proximally (base)
D.5th metatarsal avulsion
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Metatarsal fractures 5th avulsion
• Treatment same as 1‐4 metatarsal fractures, except: may start ambulation as tolerated
• Short walking cast or boot for 4 wks
• Follow up every 2‐3 wks
• Refer to Ortho: Displacement > 3 mm; step‐off > 2 mm cuboid articular surface; > 60% MT‐cuboid joint surface
Bica D, Sprouse RA, Armen J. Diagnosis and Management of Common Foot Fractures. Am Fam Physician. 2016 Feb 1;93(3):183-91.
Metatarsal fracture proximal 5th (Jones)
• Initial treatment: posterior mold, non weight bearing <1 wk
• Definitive treatment: short nonweightbearing cast or boot for 6‐8 wks.
• Repeat imaging with healing = gradual weight bearing/activity
• No healing= repeat cast/boot for 4 wks
Bica D, Sprouse RA, Armen J. Diagnosis and Management of Common Foot Fractures. Am Fam Physician. 2016 Feb 1;93(3):183-91.
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Jones Fracture
• Refer to Ortho: Displacement > 2 mm; nonunion at 12,athletes or persons with high activity level
• Consider surgical treatment
Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1307-15. doi: 10.1007/s00167-012-2138-8. Epub 2012 Sep 6. Bica D, Sprouse RA, Armen J. Diagnosis and Management of Common Foot Fractures. Am Fam Physician. 2016 Feb 1;93(3):183-91.
Jones Fracture
Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1307-15. doi: 10.1007/s00167-012-2138-8. Epub 2012 Sep 6. Bica D, Sprouse RA, Armen J. Diagnosis and Management of Common Foot Fractures. Am Fam Physician. 2016 Feb 1;93(3):183-91.
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New Proximal 5th MT Classifcation
Common 3 zone classificationMetaphyseal &
Meta‐diaphyseal
Baumbach SF., Functional treatment for fractures to the base of the 5th metatarsal - influence of fracture location and fracturecharacteristics. BMC Musculoskelet Disord. 2017 Dec 16;18(1):534. doi: 10.1186/s12891-017-1893-6.
New Prox. 5th MT Classifcation• 39 pts
• 31% displaced fx, 74% intra‐articular fx, 41% fragemented
• Type I 59%, type II 41%,
• Treatment: stiff shoe, ace wrap (optional), full wt bearing as tol.
• Repeat xray at 6 wks only if symptoms
• Resumed work 17 +/‐ 12 days, sports 53 +/‐ 22 days
• None required surgery, no complications at 6 months
Baumbach SF., Functional treatment for fractures to the base of the 5th metatarsal - influence of fracture location and fracturecharacteristics. BMC Musculoskelet Disord. 2017 Dec 16;18(1):534. doi: 10.1186/s12891-017-1893-6.
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Prox. 5th MT Fracture Treatment?
• Meta analysis
• Functional: Ace wrap, boot, post op shoe
• Weight bearing as tolerated
• NO significant difference
Janssen E, Rijpsma D., BET 1: Functional treatment is non‐inferior to below the knee cast in adults with acute closed proximal fifth metatarsal fractures Emergency Medicine Journal 2019;36:319‐320Pituckanotai, K., et al. Comparative Outcomes of Cast and Removable Support in Fracture Fifth Metatarsal Bone: Systematic Review and Meta-Analysis The Journal of Foot and Ankle Surgery Vol 57 (5) Sept/Oct 2018, 982-986 doi.org/10.1053/j.jfas.2018.03.018
• Athletes: consider surgical treatment?
• Operative 4.2x cost (Europe), better mental quality of life
• Conservative (casting) fewer complications (4.1% vs 12.9%)
Prox. 5th MT Fracture Surgical Treatment?
Porter, D. A. (2018). Fifth Metatarsal Jones Fractures in the Athlete. Foot & Ankle International, 39(2), 250–258. https://doi.org/10.1177/1071100717741856Monteban, P., van den Berg, J., van Hees, J. et al. The outcome of proximal fifth metatarsal fractures: redefining treatment strategies Eur J Trauma Emerg Surg (2018) 44: 727. https://doi.org/10.1007/s00068-017-0863-x
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Metatarsal fractures 1‐4
• Initial treatment: posterior mold, non weight bearing <1 wk
• Definitive treatment: short walking cast or boot for 6 wks
• Follow up every 2‐4 wks• Refer to Ortho: Open, displaced (>3mm), angulated (>10 °) fractures; fracture‐dislocations; intra‐articular fractures
Bica D, Sprouse RA, Armen J. Diagnosis and Management of Common Foot Fractures. Am Fam Physician. 2016 Feb 1;93(3):183-91.
Pediatric Fractures
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Salter Harris Fracture classification
8 y/o buckle fracture
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• Sensitivity: 98.4%
• Specificity: 95.3%
Buckle fracture‐ Ultrasound
Soegtrop, R. Et. Al. Point‐of‐care Ultrasound for Distal Forearm Buckle Fractures in Children: Test Performance and Pain Outcomes Pediatrics Jan 2018, 141 (1 MeetingAbstract) 353; DOI: 10.1542/peds.141.1_MeetingAbstract.353.
AES Question 5
The best immobilization option for a distal radius buckle fracture is?
a) Ace wrap
b) Rigid splint
c) Wrist brace
d) Cast
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• Short arm cast vs removable splint
• No difference in pain, healing
• Improved pt satisfaction for splint
• Cochrane: For distal forearm fractures‐ No useable conclusions
Buckle fracture cast vs splint
Plint AC, Perry JJ, Correll R, et al. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006;117:691-697 Karimi Mobarakeh M, Nemati A, Noktesanj R, Fallahi A, Safari S. Application of Removable Wrist Splint in the Management of Distal Forearm Torus Fractures. Trauma Mon. 2013;17(4):370-2Madhuri V, Dutt V, Gahukamble AD, Tharyan P. Conservative interventions for treating diaphyseal fractures of the forearm bones in children. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD008775
Buckle Fracture Rigid vs Nonrigid?
• Nonrigid: • soft cast,
• splint,
• ace bandage,
• Slab
• nonrigid better clinical efficacy, functional recovery, cost, complication
• Preferred by patients
Jiang N, Cao ZH, Ma YF, Lin Z, Yu B. Management of Pediatric Forearm Torus Fractures: A Systematic Review and Meta-Analysis. Pediatr Emerg Care. 2016 Nov;32(11):773-778.
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Buckle fracture: follow up?
• Splint for 2‐3 wks • PCP ok
• Resume activity if asymptomatic for 2 wks
• Usually resume by 4‐6 wks
• Follow up if unable to resume by 6 wks
• Choosing wisely: no follow up xray at 4 wks if asymptomatic
Ben-Yakov M, Boutis K. Buckle fractures of the distal radius in children. CMAJ. 2016 Apr 19;188(7):527. doi: 10.1503/cmaj.151239. Epub2016 Mar 14. Koelink E, Schuh S, Howard A, et al. Primary care physician follow-up of distal radius buckle fractures. Pediatrics 2016;137:1-9.
Choosing wisely. American Academy of Pediatrics – Section on Orthopaedics and the Pediatric Orthopaedic Society of North America http://www.choosingwisely.org/societies/american-academy-of-pediatrics-section-on-orthopaedics-and-the-pediatric-orthopaedic-society-of-north-america/ accessed 2/14/18
Ottawa Ankle Rules evidence in children
• > 5 y/o
• Sens: 97.5%
• Spec: 21%
• Ankle x‐ray reduction: 16‐32%
• If neg, 90% NO fracture
Beckenkamp PR, Lin CC, Macaskill P, et al. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis Br J Sports Med Published Online First: 24 November 2016. doi: 10.1136/bjsports-2016-096858 Ellenbogen AL, Rice AL, Vyas P. Retrospective comparison of the Low Risk Ankle Rules and the Ottawa Ankle Rules in a pediatric population. Am J Emerg Med 2017; 35:1262.
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• Avulsion distal fibula
• Salter I
• Salter II
• Lateral Talus
Low risk Ankle fractures
Boutis K et al. Pediatrics. 2007
• Post mold = stirrup for return to play.
• Brace superior to cast in return to function, patient preference, cost
• Cochrane: Low quality evidence to support stirrup.
Low risk fractures: post mold, stirrup, cast?
Barnett P et al. Pediatric Emergency Care 2012.Boutis K et al. Pediatrics. 2007Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD010836. DOI: 10.1002/14651858.CD010836.pub2.
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• No ED consultation of ortho required
• Posterior mold, stirrup brace, ace wrap preferred
• Determine immobilization, return to sports clinically (4‐6 wks)
• Follow up with PCP, sports med/ortho 1 week
Minimal distal fibular fractures management
Minor Distal Fibular Fractures Evidence Gleeson et al. Journal of Bone and Joint Surgery. 1996. Boutis K et al. Pediatrics. 2007. Barnett P et al. Pediatric Emergency Care 2012.
Peds low risk ankle fx brace vs cast
• Cochrane
• Limited evidence
• Faster recovery at 4 wks in peds low‐risk ankle fractures in brace vs cast
Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD010836. DOI: 10.1002/14651858.CD010836.pub2.
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Meds/Supplements for fracture
• Nsaids: no harms or risk of non‐union (SOR: B)
• Opioids have some negative correlation on healing (SOR: B)
• Alcohol no difference (SOR: C)
• Vit C. doesn’t prevent CRPS (SOR: B)
DePeter, K.C., Blumberg, S.M., Dienstag Becker, S. et al, Does the use of ibuprofen in children with extremity fractures increase their risk for bone healing complications?. J Emerg Med. 2017;52:426–432.Richards, Christopher J. et al. The Effect of Opioids, Alcohol, and Nonsteroidal Anti-inflammatory Drugs on Fracture Union Orthopedic Clinics , Vol 48 (4), 433 – 443 Evaniew N, McCarthy C, Kleinlugtenbelt YV, et al. Vitamin C to Prevent Complex Regional Pain Syndrome in Patients With Distal Radius Fractures: A Meta-Analysis of Randomized Controlled Trials. J Orthop Trauma. 2015;29(8):e235–41
Analgesics for Peds fracture‐
• Ibuprofen> acetaminophen or codeine
• Ibuprofen= acetaminophen + codeine
• No harm on healing with NSAIDS in peds (SOR: B)
• No benefit to morphine but great risk (SOR: B)
Korownyk, C., Young, J., Allan, M., Optimal pain relief for pediatric MSK injury Canadian Family Physician Jun 2015, 61 (6) e276; DePeter, K.C., Blumberg, S.M., Dienstag Becker, S. et al, Does the use of ibuprofen in children with extremity fractures increase their risk for bone healing complications?. J Emerg Med. 2017;52:426–432.Poonai, N., et al., Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial CMAJ Dec 2014, 186 (18) 1358-1363; DOI: 10.1503/cmaj.140907
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Treatment of fractures‐US or shockwave
• Cochrane: • Low‐intensity ultrasound (LIPUS), high‐intensity focused ultrasound (HIFUS), & extracorporeal shockwave therapies (ECSW)
• 12 studies, 648 fractures• Potential benefit of ultrasound, but insufficient evidence for routine use (SOR: A)
Griffin XL, Parsons N, Costa ML, Metcalfe D. Ultrasound and shockwave therapy for acute fractures in adults. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD008579. DOI: 10.1002/14651858.CD008579.pub3.
Fracture non‐union tx‐ bone stimulators• Cochrane:
• 4 RCT, 125 participants, delayed union or non‐union of long bone treated w/ electromagnetic fields
• No reduction in pain
• May offer some benefit but insufficient evidence for regular use (SOR: A)
• Meta‐Analysis: mod. Quality evidence on pain, reduced non‐union by 35%,
Griffin XL, Costa ML, Parsons N, Smith N. Electromagnetic field stimulation for treating delayed union or non-union of long bonefractures in adults. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD008471. DOI: 10.1002/14651858.CD008471.pub2. Aleem, I. S. et al. Efficacy of Electrical Stimulators for Bone Healing: A Meta-Analysisof Randomized Sham-Controlled Trials. Sci. Rep. 6, 31724; doi: 10.1038/srep31724 (2016).
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Practice Recommendations• Minimally displaced clavicle fractures can be treated with sling vs figure of 8 brace (SOR: A)
• Splint suspected scaphoid fractures in a thumb spica and repeat imaging after 10‐14 days (SOR: C)
• Lateral ankle avulsion and low risk pediatric lateral malleolus fractures can be splinted with an ankle stirrup (SOR: B)
• Radial buckle fractures can be treated with ace wrap or splint and return to activities after 2‐3 wks if improved (SOR: B)
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