Rural Fracture Care

Rural Fracture CareRural Fracture Care
THE FRACTURE SAFARITHE FRACTURE SAFARI
Chris Parfitt, MD, FRCSChris Parfitt, MD, FRCS

canadian-rural-orthopedics-cjp.ca
My websiteMy website

DisclosuresDisclosures
I do not receive any
material benefit from
any medical supply
company for trauma
equipment but…

Instead of this (vancouver)Instead of this (vancouver)

I see this! (Albreda Mountain)I see this! (Albreda Mountain)

Or thisOr this
• Mount Robson

Romance of Rural MedicineRomance of Rural Medicine
• Driving
• I operate in 2 rural
hospitals and have
clinics in 4 other
smaller towns from
McBride BC to
Nakusp BC
• So far never a bad
day on the road

Romance of Rural MedicineRomance of Rural Medicine
• Rural Canadian
SAFARI
• Be careful out there

Prize SlidesPrize Slides
• Students get first go,
residents second, and
free for all after that

Learning ObjectivesLearning Objectives
• By the end of this
session you should
be able to intelligently
discuss the
classification and
internal fixation
options for this
periprosthetic fracture
• NOT!!!!!!!!!!!!!

Learning objectivesLearning objectives
• You did not come
here to learn how to
do this
• (I am sorry!)

Learning objectivesLearning objectives
• You came here to
learn or review what
to do with this patient

Learning ObjectivesLearning Objectives
• Or this patient

Digital X-rays allow easy consultDigital X-rays allow easy consult
• If in doubt, always call
your friendly local
orthopaedic surgeon
• Please don’t mention my name!

Variety of OpinionVariety of Opinion
• Orthopaedic surgeons
are like farmers
arguing over the best
farming methods
• THIS IS WHAT I DO
ON MY FARM

Regarding distal radial fracturesRegarding distal radial fractures
Which one is false?
1. Casting does not hold reduction
2. Locking plates can hold reduction
3. In elderly (60 plus), the outcome of these
is equal whether treated with cast or
plate.
4. These fractures can be treated by a rural
family doctor

How would you immobilize this?How would you immobilize this?
1. Thumb spica cast
2. Refer for surgery
3. Below elbow cast
4. Splint

Watson’s test is:Watson’s test is:
1. Clinical test for shoulder instability
2. A clinical test for Achilles tendon tear
3. A good way to test the scaphoid
4. Sherlock Holmes’ partner’s test

What is true of this FXWhat is true of this FX
• Monteggia fracture
DL
• Called fracture of
necessity
• Can be treated by
rural family physician
• Named after famous
British surgeon

Messing up on fracture can end upMessing up on fracture can end up
giving you a criminal chargegiving you a criminal charge
• Yes
• No

Comprehensive Fracture CareComprehensive Fracture Care
• Treat the Whole Patient
• Identify and prioritize other injuries ATLS
• Always check neurovascular status of the
fractured limb
• Then

Treat the FractureTreat the Fracture
• Decision to refer
• Or treat the patient at
your own location
• What is this injury?

Fracture TreatmentFracture Treatment
ChecklistChecklist
SAFARISAFARI

FRACTURE SAFARIFRACTURE SAFARI
• SAFARI takes you on
a tour where you see
and learn about many
different animals
• Fractures are as
varied and interesting
as animals on a safari
• MNEMONIC

Principles of Fracture ManagementPrinciples of Fracture Management
SET the fracture
ARREST (immobilize)
FOLLOW-UP
ACTIVATE
REHABILITATE
INVESTIGATE
I

1. Set (reduce) the Fracture1. Set (reduce) the Fracture
• Start with a straight
bone
• Alignment never
improves with follow-
up!!!

What is acceptable angulationWhat is acceptable angulation
• Acceptable angulation
is where you END UP
• Most fractures wander
a bit in casts
• Patients have little
tolerance for acceptable
angulation

2. Arrest (immobilize)2. Arrest (immobilize)
Surgeons arrest
(immobilize) with
internal fixation
1. In your rural
hospital you will
use a cast or splint

After immobilizationAfter immobilization
• ELEVATION
AND ICE
• ELEVATION
AND ICE
• ANALGESIA

3. Follow-up of Fractures3. Follow-up of Fractures
• In adults and
adolescents TAX
weekly for most
• In small children TAX
every 3 to 4 days
(they heal fast)
• Follow until healing
prevents
displacement

3. Followup fractures3. Followup fractures
• Always check the X-
ray yourself or get a
verbal report
• Never rely on the
written report

4. Activate the limb4. Activate the limb
• Start activation of the
limb on your first
follow-up visit
• Helps prevent CRP
syndrome

4. Activation of the Limb4. Activation of the Limb
• Start immediate ROM of
restricted joints
• Weekly TAX sessions a
good opportunity to
monitor limb condition
and encourage ROM
and strengthening

5. Rehabilitate5. Rehabilitate
• Healing comes from
within, therapist is
motivator but has
special techniques
that can help
• Always offer some
physio
• Be aware of third
party issues

6. Investigate6. Investigate
• 6. Determine the
need for investigation
of the cause of the
fracture, i.e.
osteoporosis, child
abuse, balance
disorders, etc.

Principles of Paediatric fracturesPrinciples of Paediatric fractures
• Fractures In growing
bones
• From birth

Principles of Paediatric FracturesPrinciples of Paediatric Fractures
• Until the growth
plates close
• This patient has
almost mature bones,
but the rest of him…?

Paediatric Fractures EtiologyPaediatric Fractures Etiology
• Accidental injuries
Vs
• No accidental injury
(NAI)

Paediatric fractures NAIPaediatric fractures NAI
NAI or child abuse
fractures
Miss NAI at the
patient’s and your
peril!

Children's Fractures NAIChildren's Fractures NAI
• Most commonly in
ages less than 3
• Most specific
fractures are
• 1. Metaphysial corner
or bucket handle
fractures
• (almost diagnostic for
NAI)

• Corner fracture
(diagrammatic)

Paediatric fractures: NAIPaediatric fractures: NAI
Typical fractures
Rib fractures

• Typical fractures:
• Skull
• Sternum
• Scapula

TAKE HOME MESSAGE NAITAKE HOME MESSAGE NAI
Have high index of
suspicion for non
accidental injuries
Get social worker
involved early
Treat parents with
dignity
Eg medicolegal case

Paediatric fractures’ classificationPaediatric fractures’ classification
• Salter Harris
classification
• Dr Salter from
Toronto
• Dr Robert Harris also
from Toronto

Salter mnemonicSalter mnemonic
• Salter Harris 1
• 5%
• S
• Straight through

Type 2
• 75%
• A
• Away from growth
plate

• Salter Harris Type 3
• 10%
• L
• Fracture below the
physis

• Salter Harris Type 4
• 10%
• TE
• Through everything

• Type 5
• Rare
• R
• Rammed (crushed)

Premature physial closurePremature physial closure
• Complication of
growth plate injuries
• Common in tibia and
femur (even in grade
1 and 2 injuries)

• Distal radius fractures
• Less common than
lower limb
• Angular deformity
better tolerated in
upper limb

• Reduction restores
alignment, but does
NOT change the
incidence of
premature physial
closure
• Journal Ped.
Orthopaedics 2013

TAKE HOME MESSAGETAKE HOME MESSAGE
• Treat as any other
fracture (SAFARI)
• Always mention
premature physial
closure to parents
• Follow-up for 6
months at least post
fracture

Principles of CastingPrinciples of Casting
• Good casting is an art
form
• You can use plaster
but fiberglass is
lighter and lasts
longer
• Plaster casts get wet
and soft and have to
be replaced

• Keep the cast well
padded
• Keep the cast light
• And not too tight
• AND

• Use three point
moulding for fractures
which are unstable

• Cast is like a form for
hardening cement
• The form comes off
when the concrete
sets

How long for the castHow long for the cast
• Until fracture heals
enough to hold
alignment
• 2 yo 2 weeks
• Metaphyseal fractures
heal faster than
diaphysis
• Adult 6 plus weeks

Comprehensive Care of FracturesComprehensive Care of Fractures
• S
• A
• F
• A
• R
• I

METACARPALMETACARPAL
FRACTURESFRACTURES

Metacarpal Fractures:Metacarpal Fractures:
AssessmentAssessment
• Swelling
• Only really important
observation is
assessment of
rotation of fingers

Metacarpal Fractures X-raysMetacarpal Fractures X-rays
• True AP

Metacarpal Fractures: X-raysMetacarpal Fractures: X-rays
• True lateral
• Oblique view
increases apparent
saggital deformity
because the 5th
metacarpal is a
slightly curved bone

Acceptable AngulationAcceptable Angulation
of Metacarpal Fracturesof Metacarpal Fractures
• Up to 40 degrees metacarpal neck 5
• More proximal fracture creates more
deformity, accept less deformity
• Metacarpals 2 and 3 accept little, 5 to 10
degrees of deformity
• Rotational deformity not acceptable

Metacarpal # ReductionMetacarpal # Reduction
• Easy to straighten the
bone with Marcaine
block around fracture
• Use Marcaine with
epi and a long 25
needle
• Easier a few days
after injury

Metacarpal # ImmobilizationMetacarpal # Immobilization
• Ulnar gutter is
traditional
• Gives comfort to the
patient and comfort to
the doctor
• Doesn’t hold
alignment

Pedestal CastPedestal Cast
• Holds wrist in
GENTLE extension
with moulding under
metacarpal head
• Effective to displaced
fractures after
reduction

Metacarpal Fractures: RxMetacarpal Fractures: Rx
• Because the wrist
wants to fall into
relative flexion, there
is always pressure on
the metacarpal head

Metacarpal Fractures: RxMetacarpal Fractures: Rx
• Frontal view of cast
with pressure point
under fractured
metacarpal head

Example metacarpal fractureExample metacarpal fracture
• Lateral X-ray

Example Case Metacarpal fractureExample Case Metacarpal fracture
• Reduced
• Pedestal cast

Metacarpal Fractures: FollowupMetacarpal Fractures: Followup
• Now just follow with
weekly X-rays for 4 to
5 weeks and take the
cast off and start
range of motion of the
MCP joint
• Results good if
patient compliant

Reasons for ReferralReasons for Referral
• Open injuries
• Rotational deformity
• Multiple unstable
fractures
• Patient demand

Scaphoid FracturesScaphoid Fractures
• Need to diagnosis
before you can
manage it

Scaphoid Fractures: DxScaphoid Fractures: Dx
• History: dorsiflexion
injury
• Snuffbox tenderness

Watson’s testWatson’s test
• Very sensitive test for
scaphoid fractures
and scapholunate
separations
• Find the tuberosity of
the scaphoid

• Put your thumb on the
tubersity as you hold
the wrist

• Ulnar deviate the
wrist
• This extends the
scaphoid

• Radial deviate the
wrist
• This flexes the
scaphoid
OUCH!

Scaphoid # XraysScaphoid # Xrays
• Wrist with scaphoid
view
• Negative X-ray
• Immobilize and
follow-up

Scaphoid investigationScaphoid investigation
• Recent summary
discourages 2nd
xray,
but you are rural
• Arrange a CT if
clinical suspicion
(93% sensitivity)

Scaphoid # negative X-raysScaphoid # negative X-rays
• If CT negative and
still clinically
suspicious
• Arrange a bone scan
(100% sensitivity)

Scaphoid fractures TreatmentScaphoid fractures Treatment
• Refer proximal
fractures or displaced
fractures
• Undisplaced fractures
can be treated
operatively or
operatively

Scaphoid # immobilizationScaphoid # immobilization
• The old

Casting scaphoid fractureCasting scaphoid fracture
• The new (Schramm
2007)
• The thumb can be left
free at the MCP joint
• Much more functional
cast
• Much happier patient

Scaphoid # follow-upScaphoid # follow-up
• Review every 4
weeks
• Expect 10 to 12
weeks for healing!

Scaphoid Fractures: RxScaphoid Fractures: Rx
• X-rays are not
conclusive to prove
healing
• Once you are fairly
sure it is healed, put
in a splint and
arrange a CT scan

Scaphoid Fractures: SurgeryScaphoid Fractures: Surgery
• Some subspecialty
papers point to the
advantage of fixing all
scaphoid fractures
• Same healing time,
but less time in a cast
and less time off work

Scaphoid SurgeryScaphoid Surgery
• However, most larger
reviews and
metanalyses show no
benefit of surgery for
undisplaced fractures
of the scaphoid
• Always some
complications with
surgery

Scaphoid FracturesScaphoid Fractures
• Indications for referral • 1. Displaced
fractures more than
1mm
• 2. Proximal fractures
• (60 to 70 % healing in
a cast)
• 3. Patient and
Surgeon preference

Scaphoid Fractures: SurgeryScaphoid Fractures: Surgery
Proximal displaced
fracture
Refer this one

Distal Radial FracturesDistal Radial Fractures
• foosh

Normal Anatomy distal radiusNormal Anatomy distal radius
Anterior Posterior view
Radial length

Normal Anatomy distal radiusNormal Anatomy distal radius
• Lateral view
• 11 degrees volar
angulation

• Usual deformity is
dorsal angulation and
radial shortening and
radial fall-off
• Talking about Dorsal
angulated fractures

Goal of ReductionGoal of Reduction
Poor outcome related to
1. Intra- articular step
deformity > 2mm
2. > 11 degrees of
dorsal angulation
3. >3 to 4 mm of radial
shortening

Goal of ReductionGoal of Reduction
• Younger adults should be restored to as
anatomical as possible
• Older adults should be reduced to at least
neutral on the lateral film and try to
minimize radial length loss

Cycling of Ortho opinionCycling of Ortho opinion
• 5 years ago ortho
trauma wrist
specialists were
saying these all
should be plated

Distal Radial FractureDistal Radial Fracture
• Arora 2009
• Dr. Geoff Johnstone in Saskatoon followed 400
cases and found same results in casting or
surgery 2014
• Anatomic plating gives no better function and
patient satisfaction than cast treatment in older
patients (over 70 years of age)
• Regardless of the X-ray!

Distal Radial # ReductionDistal Radial # Reduction
• Anesthesia can be
achieved with a
hematoma block
• Or conscious
sedation

Distal Radial Fractures:Distal Radial Fractures:
ReductionReduction
• Reduction is achieved
by milking the
fragments with
traction on the thumb
and radial fingers

Distal Radial Fractures:Distal Radial Fractures:
ReductionReduction
• Patient laying on
stretcher
• Have plaster or
fiberglass with warm
water ready to go

Distal Radial # ImmobilizationDistal Radial # Immobilization
• Start below elbow
• Pad above elbow
• Mold as the cast
hardens
• CASTING IS SAFE
AND BETTER THAN
SPLINT

Distal Radial Fx: CastingDistal Radial Fx: Casting
• Cast is not too tight
• Just 3 point molding
• Below elbow
• Send home with
analgesics, elevation
and ice

Distal Radial Fx: CastingDistal Radial Fx: Casting
• Always leave the
fingers free at the
MCP joints
• Encourage ROM
• Elevation always
• Pain control

Example Distal Radial FractureExample Distal Radial Fracture
• Initial angulation

Example distal radial fractureExample distal radial fracture
• Hematoma block and
casting
• Invisible composite
casting

Example distal radial fractureExample distal radial fracture
• Splint, refer from ER

Example Distal Radial FractureExample Distal Radial Fracture
vocal anaesthesia
• Molded cast

Goal of Severely displacedGoal of Severely displaced
fracturesfractures
• By improving the
position of the
fracture, you take the
neurovascular
structures out of risk
and reduce the need
for urgent surgery

Distal Radial Fx: Follow-upDistal Radial Fx: Follow-up
• TAX weekly
• Any fall off that is
significant for the age
should be referred
• Cast removal at 5
weeks and start
physio

Surgery Distal radial fracturesSurgery Distal radial fractures
• Indications
• 1. Unacceptable position for age and
activity level of patient
• 2. Smith’s fracture
• ALWAYS REFER EARLY ENOUGH FOR
SURGERY (2 WEEKS OR LESS)

Smith’s FractureSmith’s Fracture
• This fracture always
needs operative
fixation
• Volar angulation!

Surgery distal radiusSurgery distal radius
• Locking plate
• Screws thread into
the plate
• Holds the fracture at
the set angle

Surgery Distal Radial #Surgery Distal Radial #
• Locking plate gives
early stability
• American surgeons
fix all of these
fractures
• Complication rate
20% in most studies

Answer Pre Test distal radiusAnswer Pre Test distal radius
• 1. Casting can hold fracture position
acceptable
• 2. Plating very good at holding reduction
• 3. In patients over 60 long term results
same in casting versus plating
• 4. Rural family doctors can treat many of
these fractures successfully

END SESSION ONEEND SESSION ONE
• FRACTURE SAFARI
ONLY HALF DONE!
• Questions about first
half?

Session two Fracture SafariSession two Fracture Safari
• Thankyou for
returning

Forearm # AssessmentForearm # Assessment
• This is the fracture
highly associated with
COMPARTMENT
SYNDROME
• Think of this in your
assessment
• Let pain be your
guide

Forearm # Acceptable anglesForearm # Acceptable angles
Age less than 6 --25
degrees
Age 6 to 10--15 degrees
Age 10 to 12—10
degrees
Rotation 30 degrees
END UP HERE
Adult - anatomic

Forearm # ReductionForearm # Reduction
• Conscious sedation
• Reduce with thumb
pointing towards the
apex of the fracture
• ie. Pronate with volar
apex, supinate with
dorsal apex

Forearm # immobilizationForearm # immobilization
• Long arm cast always
• 3 point molding
• ELEVATION AND
ICE

Forearm# Follow-upForearm# Follow-up
• X-ray weekly or more
frequent in younger
children
• Don’t wait for the
report to get to your
desk

Forearm # follow-upForearm # follow-up
• Forearm (diaphysial)
fractures heal slower
than metaphysial
fractures
• Continue casting, first
long arm then short
arm until solidly
healed 8 weeks
minimum

Forearm # internal fixationForearm # internal fixation
• Any displaced adult
fracture
• Proximal fractures in
children >6 years old
• Distal fractures when
less than 2 years of
growth left

Forearm # Internal FixationForearm # Internal Fixation
• For paediatric
fractures
• Intra-medullary wiring

Forearm # Internal FixationForearm # Internal Fixation
• For adults
• Compression plate
fixation

Forearm fracture dislocatonsForearm fracture dislocatons
• Galleazi fracture
dislocation
• Called fracture of
necessity (needs
surgery)
• Refer this one

Galleazi Fracture DLGalleazi Fracture DL
• Treated with ORIF of
radius

Monteggia fracture DLMonteggia fracture DL
• In X-ray of elbow the
radius always lines up
with the capitellum

Monteggia Fracture DLMonteggia Fracture DL
• Radius always lines
up with the capitellum
• REGARDLESS OF X-
RAY VIEW

• Fracture ulna with
dislocation of radial
head

• Needs open reduction
internal fixation in
adults
• Closed reduction in
children
• Refer all

Pediatric elbow fracturesPediatric elbow fractures
• These are :
• UNFORGIVING
• fractures

Paediatric Elbow #Paediatric Elbow #
• Radial head always
Lines up with the
Capitellum
Anterior humeral line
Passes through
Middle third of
capitellum

Elbow Fat pads:Elbow Fat pads:
• Visualization of the
_____? pad can be
normal
• Visualization of the
______? pad is
always pathological

Sail (spinnaker) signSail (spinnaker) sign
• Shaped like a sail

Paediatric Elbow FracturesPaediatric Elbow Fractures
• These fractures are
very unforgiving
• Recognize all
• Refer all
• Except the
undisplaced supra-
condylar fracture

Supra-condylar # ImmobilizationSupra-condylar # Immobilization
• Safari
• Cast or splint elbow at
90 degrees
• X-ray every 5 days or
so
• Cast on 3 to 4 weeks

Type 3 Supra-condylar #Type 3 Supra-condylar #
• Brachial artery may
be damaged or
blocked by the distal
humeral fracture
• Urgent referral
• Reducing in flexion
may bring back pulse

Type3 supra-condylar #Type3 supra-condylar #
• Urgent reduction and
fixation

T condylar elbow fractureT condylar elbow fracture
• Complicated but not
compound

T condylar fractureT condylar fracture
• ORIF with olecranon
osteotomy

OLECRANON FRACTURESOLECRANON FRACTURES
• Undisplaced
• Can treat with
SAFARI
• Splint 90 degrees
• Start RoM at first sign
of healing, 3 to 5
weeks

Olecranon FracutresOlecranon Fracutres
• Displaced

Olecranon Fracture displacedOlecranon Fracture displaced
• Always needs orif

Radial head fracturesRadial head fractures
• There are several
degrees of
displacement
• Most minimally
displaced

Radial Head FracturesRadial Head Fractures
• Pass xrays by your
friendly local
orthopod
• Treat with early range
of motion
• See weekly, xray in 3
and 6 weeks

Radial Head FracturesRadial Head Fractures
• Orthopedic surgeon
may elect to fix or
replace more severe
fractures

Questions forearm and ElbowQuestions forearm and Elbow
fractures?fractures?
• S
• A
• F
• A
• R
• I

Humeral shaft FracturesHumeral shaft Fractures
• Torsional force
causes oblique
fracture
• Direct blow causes
transverse fracture

Humeral # assessmentHumeral # assessment
• Neurovascular Check
• Always check the
radial nerve!
• No wrist, finger or
thumb extension

Humeral FractureHumeral Fracture
• Start with sugar tong
splint in ER

Humeral Shaft # ImmobilizationHumeral Shaft # Immobilization
Definitive conservative
care is best with the
Sarmiento humeral
fracture brace.80 to
90% heal with
conservative care

Sarmiento humeral splintSarmiento humeral splint
• Physio may fabricate,
however
commercially
available for about
300$

Humeral shaft # FollowupHumeral shaft # Followup
• X-ray every 2 weeks
• Average 8 to 10 week
healing time

Surgical RX Humeral Shaft #Surgical RX Humeral Shaft #
• Proximal oblique
fractures
• Other shaft fractures
with poor apposition
and alignment

Update ORIF humeral fracturesUpdate ORIF humeral fractures
• Better surgical
equipment and
specialized skills are
becoming an option
for care of this
fracture
• Patient factors and
decisions

Humeral # acceptable angulationHumeral # acceptable angulation
• 20 degrees saggital
• 30 degrees coronal
• 15 degrees rotation
• 3cm shortening

Humeral shaft # surgeryHumeral shaft # surgery
• This one treated in a
Sarmiento splint for 3
months
• Smoker
• No callous

Humeral shaft # surgeryHumeral shaft # surgery
• Plate fixation is the
standard for fixing
these fractures
• IM nailing only for
pathological fractures

Clavicle FracturesClavicle Fractures
• Most not severely
displaced
• Conservative RX
appropriate
• 90% treated
conservatively

Clavicle Fracture Follow-upClavicle Fracture Follow-up
• Don’t expect healing
for at least 6 weeks
• Refer for delayed and
non unions

Displaced Clavicle FracturesDisplaced Clavicle Fractures
• Multicentre Canadian
study changed the
management of some
of these fractures
• McKee et al 2007
• I had this # in 1993
and saw 3 surgeons
to get it plated

• Indications for surgery
(2007 Mckee)
• >2cm of shortening
(said worse functional
outcome)
• Fracture ends apart

• More recent review of
clavicle fractures
• Operative treatment
no benefit over non
operative treatment
• Cochrane review
2013

• McKee et al 2012
• ORIF can shorten
disability time and
reduce the incidence
of symptomatic non
union but little
evidence to show that
long term function
improved with ORIF

Clavicle # variety of opinionClavicle # variety of opinion
• Dr. Roy Sanders
(high level US trauma
surgeon)
• He had displaced #
clavicle (his own rx
non op)
• Does not operate
primarily on clavicle #

Recent summary Clavicle #Recent summary Clavicle #
• Refer those at risk of
delayed/ non union
• 2cm displacement
• Female
• Smokers?
• Patient demand

Clavicle # ImmobilizationClavicle # Immobilization
• Traditional figure of 8
• Like many of our
traditional practices
this has no proven
benefit . Let the
patient use what is
most comfortable eg.
sling

Surgery Treatment Clavicle #Surgery Treatment Clavicle #
• Impending open
fracture

Case: Fracture ClavicleCase: Fracture Clavicle
• Will this one heal?
• Yes
• No

Clavicle fractureClavicle fracture
• Yes!

Proximal Humeral FracturesProximal Humeral Fractures
• Usually osteoporosis
• Majority (80%) are not
significantly displaced

Proximal Humeral Fractures:Proximal Humeral Fractures:
AssessmentAssessment
AP X-ray

Proximal humeral# X-raysProximal humeral# X-rays
• Another AP Xray
What do you expect this
is?

Need Axillary viewNeed Axillary view
• Posterior dislocation

Proximal Humeral X-raysProximal Humeral X-rays
• Axillary view
• X-ray techs can be
difficult to convince
but will comply if
instruction understood
• Legal liability to treat
without this view

Proximal Humeral Fractures:Proximal Humeral Fractures:
Displacement CriteriaDisplacement Criteria
• > 45 degrees of
angulation
• Displacement greater
than 1 cm of parts
(head, GT,LT and
shaft)

Proximal Humeral Fractures: CTProximal Humeral Fractures: CT
• 3 dimensional CT
• Takes away the
guesswork

Proximal HumeralProximal Humeral
Fractures: RxFractures: Rx
• Undisplaced (80%)
need shoulder
immobilizer
• Weekly X-ray
• NO PHYSIO UNTIL
SIGNS OF HEALING
on X-ray
• Usually 4 to 5 weeks

Proximal Humerus SurgeryProximal Humerus Surgery
• Unstable 4 part
fracture

Proximal Humerus SurgeryProximal Humerus Surgery
• Many different locking
plates available

Proximal Humeral SurgeryProximal Humeral Surgery
• Hemi-arthroplasty

Reverse Shoulder ReplacementReverse Shoulder Replacement
• New kid on the block
• For shoulder arthritis
with absent rotator
cuff OR
• Comminuted
proximal humeral
fractures OR
• Malunited fractures

Proximal Humeral FracturesProximal Humeral Fractures
• Hot off press
• In elderly, surgical vs
conservative care all
displaced 3 and 4 part
fractures had equal
outcome!
• Jawa et al AAOS
2014

Interesting caseInteresting case
• What do you do here
• Look before you leap

Proximal Humeral surgeryProximal Humeral surgery
• Your reduce it and
now you have this
• 20% of dislocations
with greater tuberosity
fractures have
undisplaced surgical
neck fractures

Questions humerus and clavicleQuestions humerus and clavicle
fracturesfractures
• S
• A
• F
• A
• R
• I

Subcapital Fracture HipSubcapital Fracture Hip
• These fractures are
the most important
ones for you because
the undisplaced ones
are , like a scaphoid
fracture, difficult to
diagnose
• Medico-legal issues

Subcapital Fracture HipSubcapital Fracture Hip
• Injury, followed by hip
pain and difficulty
bearing weight is a
fracture until proven
otherwise
• MRI best, CT second
best, bone scan not
great
• Keep patient non wt
bearing

Sub capital fracture hipSub capital fracture hip
• Undisplaced fractures
can be
percutaneously
pinned a 20 minute
operation

Displaced Subcapital Hip #Displaced Subcapital Hip #
• In patients under the
age of 55 or so this
should be pinned with
the hope to save the
hip. Risk of
avascular necrosis
• THIS IS THE ONLY
EMERGENCY HIP
FRACTURE

Displaced Subcapital # hipDisplaced Subcapital # hip
• Arthroplasty for older
people
• Either bipolar or total
hip replacement

Hip FracturesHip Fractures
• Inter-trochanteric hip
fracture
• You diagnosis this
and send it to the
surgeon

Intertrochanteric Fracture FixationIntertrochanteric Fracture Fixation
• Dynamic hip screw
• This construct is 40
years old and is now
generally retired
• Unacceptable
incidence of fixation
failure

Intertrochanteric fracture fixationIntertrochanteric fracture fixation
Intramedullary fixation is
now the fixation of
choice. Allows early
weight bearing and
much lower incidence
of fixation failure

Hip Fractures FollowupHip Fractures Followup
• This is your job in a
rural community
• The surgeon did the
SA
• You do the FARI

Hip Fracture Weight BearingHip Fracture Weight Bearing
Internally fixed fractures are
very variable, most with
good fixation can walk
weight of leg
Arthroplasty can weight
bear early just like a total
hip
Always ask surgeon!

Hip # AnticoagulationHip # Anticoagulation
• Most health care
organizations
recommend 14 to28
days average for
chemical
anticoagulation

Hip # InvestigationHip # Investigation
• Over 80 % of older
hip fracture patients in
a Seattle study had
deficiency of VIT D
and Calcium
• You may need to do
densitometry

Femoral Shaft FracturesFemoral Shaft Fractures
• When the only tool
you have is a
hammer, then every
problem starts to look
like a nail

Femoral shaft fractureFemoral shaft fracture
• This is the standard of
care in the older child
and the adult patient

Paediatric Femur FracturesPaediatric Femur Fractures
• Up to age 5 a spica
cast is used

Paediatric femoral fracturesPaediatric femoral fractures
• Middle age group use
intramedullary wires

Patellar FracturePatellar Fracture
Undisplaced fractures
SAFARI

Patellar Fractures UndisplacedPatellar Fractures Undisplaced
Reduction not needed
Immobilization –
cylinder cast or a
brace to hold in
extension(more
comfortable)
Follow-up – weekly
Start physio after 3 to 4
weeks and dc cast or
splint

Patellar FracturesPatellar Fractures
• Displaced fractures
• Refer for surgery

Patella FracturesPatella Fractures
• ORIF patellar fracture

PRIZE QUESTION, what is thisPRIZE QUESTION, what is this
• Hint, pediatric
• Can’t extend knee

Tibial Shaft FracturesTibial Shaft Fractures
• Acceptable angulation
in both adults and
children
• Rotary or angular
deformity < 5 degrees
• < I cm of shortening
• 10 degrees anterior
angulation in children

Tibial Shaft PaediatricTibial Shaft Paediatric
• Most treated in long
leg casts
• SAFARI

Tibial Shaft# follow-upTibial Shaft# follow-up
• Weekly X-ray
• encourage non weight
bearing
• Patellar tendon
bearing cast as soon
as some healing on
X-ray

Tibial shaft # adult displacedTibial shaft # adult displaced
• Most of these are
nailed

Ankle FracturesAnkle Fractures
• Need an X-ray to
make diagnosis
• Ottawa’s rules help
Ottawa to save
money
• Lawyers’ rules are
different

Ankle fracture assessmentAnkle fracture assessment
• Routine history
• Physical should look
for pulses as
chronically ischemic
feet are a
contraindication for
surgery
• Always examine for
medial and lateral
tenderness

Ankle Fractures: UndisplacedAnkle Fractures: Undisplaced
• Mostly lateral
malleolus fractures
• Usually quite stable
• SAFARI

Ankle fracture undisplacedAnkle fracture undisplaced
• Lateral view helps
decide whether
operative or not
• Less than 3 to 4mm
displacement on the
lateral view
acceptable for cast or
roboboot

Ankle Fracture immobilizationAnkle Fracture immobilization
• Roboboot is much
better than a cast
• Should be in your
emergency rooms
cost about 100$
• Weight bearing
depends on fracture

Ankle Fracture followupAnkle Fracture followup
• X-ray weekly for 4 to
5 weeks
• Watch for talar shift
• Or fibular
displacement

Talar ShiftTalar Shift
• Lateral shift of the
talus
• Where is the patient
tender
• What is the treatment

Talar Shift: RxTalar Shift: Rx
• Tell the orthopod that
this patient needs a
syndesmosis screw
• Orthopods generally
don’t like being told
what to do so you
now really have
his/her attention

Ankle Fractures: DisplacedAnkle Fractures: Displaced
• Almost all of these
displaced fractures
need to be reduced
and fixed

Displaced Ankle fracturesDisplaced Ankle fractures
• Surgical reduction
leaves 95% good
results

Ankle Fracture closed RX?Ankle Fracture closed RX?
• Does this need open
reduction?

Ankle Fracture Closed RX?Ankle Fracture Closed RX?
• Emergency doctor
reduced under
conscious sedation
• Healing anatomically
in cast
• Don’t underestimate
your skills

Ankle Fracture dislocationAnkle Fracture dislocation
• What to do?

Fracture dislocationFracture dislocation
• Always reduce this

Ankle Fractures:Ankle Fractures:
Negative X-raysNegative X-rays
Negative ankle X-rays
with swelling and pain
after an injury
SHOULD NOT BE
REASSURING

Ankle Fractures: Negative X-Ankle Fractures: Negative X-
raysrays
• Always examine the
foot with an ankle
sprain

Ankle Fractures: Negative X-Ankle Fractures: Negative X-
raysrays
• Always examine
Achilles tendon

Ankle fracture negative x raysAnkle fracture negative x rays
• Ankle X-ray can show
a lateral process talar
fracture

Lateral Process Fracture of theLateral Process Fracture of the
TalusTalus
• Snowboarder’s
fracture
• Easily missed
• Prognosis is not great
• Particularly with any
displacement

Foot FracturesFoot Fractures
• The foot is famous for hiding midtarsal
and tarsal fractures on X-rays
• Have a high clinical suspicion and a very
low threshold to order a CT scan and refer
the patient

• Calcaneal Fractures
• Complex decisions if
displaced
• Treat undisplaced
with NWB and
monthly x rays

• Displaced calcaneal
fractures
• Ortho surgeon may
elect to operate

Foot fractures LisfrancsFoot fractures Lisfrancs
• Even minimal
displacement of the
midtarsal joints can
give permanent
disability

ALERT LISFRANCS INJURYALERT LISFRANCS INJURY
• Now most commonly
missed msk injury
• High medicolegal risk
• Clinical exam of foot
always
• If unsure put on
crutches and reasses
in a few days
• Weight bearing view

Foot fracturesFoot fractures
• Metatarsal fractures
• Treat with cast or
roboboot if well
aligned.
• Refer if significant
misalignment

Base of 5Base of 5thth
metatarsal fracturemetatarsal fracture
• Common
• Fix only those with
marked displacement
• SAFARI

Questions lower limb fracturesQuestions lower limb fractures
• S
A
F
A
R
I

• 1. casting always loses some reduction
• 2. plating holds reduction
• 3. recent studies demonstrate equal
outcome in patients age 60 treated with
casting or plating
• 4. rural family doctors can treat displaced
distal radial fractures

Missing a NAI in child can land youMissing a NAI in child can land you
in courtin court

Scaphoid casts are passeScaphoid casts are passe
• Just immobilize to
MCP joint

Watson’s Test?Watson’s Test?
• Elementary my dear Watson

Remember this guy!Remember this guy!
• Don’t call him after
things have gone
wrong!
• If you do, instead of
calling a god, you will
be calling…

This GuyThis Guy
• Godzilla
• And, please, please don’t mention my name!

Thank you for coming on theThank you for coming on the
Fracture SafariFracture Safari

Rural Fracture Care

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