Common Fractures Flashcards
Fingertip Fractures
Also known as tuft fractures
Occur in the distal phalanx
Often due to a crush injury→ transverse or comminuted fracture
Signs & Symptoms
Pain
Swelling
Hyperesthesia: excessive sensitivity that can be persistent
Bleeding between the nail plate and the nail bed = subungual hematoma
finger fracture
Diagnosis & Treatment
Diagnosis
Based on physical examination and plain-film x-rays
AP, lateral, and oblique views of the affected finger
Treatment
Protective covering to the affected finger for 2-4 weeks
Nail trephination for large or painful subungual hematoma
Large nail bed lacerations require repair with sutures if evaluated with 24 hours of the injury and show no signs of infection
Metacarpal Fractures
general
Usually result from axial load (punching with a clenched fist)
Document the mechanism of injury → punching someone in the mouth with resulting MCP wound = fight bite → start antibiotics
5th metacarpal is the most common metacarpal fracture (Boxer’s fracture)
Metacarpal Fractures
Signs & Symptoms
Pain
Swelling
Sometimes rotational deformity
Most common in oblique and spiral fracture types
PIP joints at 90˚ flexion normally converge at a point in the proximal carpal bones (scaphoid)
Deviation of one or more of these lines, suggests a metacarpal fracture
Associated extensor tendon laceration
Left: Boxer’s fracture with angulation
Right: fight bite
metacarpel Fx
Diagnosis & Treatment
Diagnosis
Based on physical examination and plain-film x-rays
AP, lateral, and oblique views of the affected hand
Classified as fractures of the head, neck, or shaft
Treatment
Immobilization with an ulnar gutter splint for 4th and 5th metacarpal fractures for 4 weeks
MCP joints at 70-90˚ of flexion
Reduction is required for:
Rotational deformity of any metacarpal
Fractures of the 2nd and/or 3rd metacarpals with angulation
Operative management for open fractures, intra-articular fractures, significant displacement or angulation, multiple metacarpal fractures
Scaphoid Fractures
Most commonly injured carpal bone
Usually results from wrist hyperextension injuries (fall onto an outstretched hand (FOOSH))
scaphoid fx
Potential for severe complications:
Osteonecrosis due to disruption of the blood supply (dorsal branch of the radial artery) which enters the distal pole of the bone
The more proximal the fracture, the greater the risk for osteonecrosis
Nonunion
scaphoid fx
S/Sx signs
3 ways to induce pain/tenderness
Radial side of the wrist:
Pain
Swelling
Specific signs
Pain with axial compression of the thumb
Pain during wrist supination against resistance
Tenderness in the anatomical snuffbox during ulnar deviation
scaphoid fx
Dx
Based on physical examination and plain-film x-rays
PA, PA ulnar deviation, lateral, and oblique views
May NOT be visible on initial x-ray
Scaphoid
Tx and follow up
Treatment
For confirmed or suspected fracture, the patient is placed in a thumb spica splint
Referral to orthopedics
Suspected fractures will be re-examined in 1 week; if pain or tenderness persists, repeat plain-film x-rays are obtained
Persisting clinical suspicionafter negative repeat radiographs warrants MRI or CT scan
Distal Radius Fractures
types and S/Sx
Colles fracture
Fall onto an outstretched hand (FOOSH)
Radial fracture with dorsal displacement and angulation
A fracture to the ulnar styloid is often present
Smith fracture
Fall onto a flexed wrist or direct blow to the wrist
Radial fracture with volar displacement
Signs & Symptoms
Pain
Swelling
Deformity – dinner fork v garden spade deformity
Abnormal function of the median nerve
Numbness to the tip of the index finger
Weakness with thumb and finger pinching
distal radius fracture
Dx and Tx
Follow up?
Diagnosis
Based on physical examination and plain-film x-rays
AP, lateral, and oblique views
If intra-articular involvement is unclear, a CT scan may be needed
Treatment
Closed reduction
If the fracture is open or if closed reduction is unsuccessful, open reduction with internal fixation (ORIF) by orthopedics may be necessary
Volar splint with the wrist at 15-30˚ extension
Orthopedic follow-up in 1 week
Radial Head Fracture
general
Radial head:
Palpated over the lateral elbow
Rotates during pronation and supination
Articulates with the lateral epicondyle of the humerus
Most common in adults
Results from a fall on an outstretched arm
Radial head fx
S/Sx
Signs & Symptoms
Pain at the radial head
Worse with palpation
Worse with supination
Limited passive ROM
radial head fx
dx
Based on physical examination and plain-film x-rays
AP, lateral, and oblique views of the elbow
Fracture is often difficult to see on x-ray
Joint effusion is often present
Anterior fat pad is nonspecific
Posterior fat pad – presume there is a fracture
Radiocapitellar line
Line through the midshaft of the radius on lateral x-ray that should transect the middle of the capitellum…if it does not, an occult fracture is probably present
radial head fx
tx
Sling
Minimal displacement and no restriction of passive elbow motion or instability
Elbow range-of-motion exercises should be started as soon as tolerable
Surgical repair
Elbow instability
Elbow motion that is mechanically blocked
Supracondylar Fracture
general and S/Sx
Fracture to the distalhumerus, just above the elbow joint
Most common traumatic fracture in children
Results from a fall onto an outstretched hand (FOOSH)
Signs & Symptoms
Pain
Deformity
Swelling
↓ range of motion
Nerve injury: median and/or radial nerves
Supracondylar Fracture
Neuro examination
Repetitively evaluatemotor andsensory nerve function and assess forvascular insufficiency
Neurological exam:
Median nerve: assess for abduction of thumb orflexionof distal phalanx of thumb
Anterior interosseous nerve (AIN): assess forflexionof distal phalanx of thumb; okay sign
Radial nerve: assess forextensionof wrist
Supracondylar Fracture
Vascular exam
Vascular exam:
Evaluate for discoloration, warmth of limb, and capillary refill
Evaluate both radial and ulnar arteries
Cold, pale, pulselesshandrequires immediate surgical evaluation andfracture reduction
Supracondylar Fracture
Dx
Based on physical examination and plain-film x-rays
AP and lateral views of the elbow; true lateral is essential
Findings on abnormal radiographs:
Visible posterior fat pad
Wide (sail sign)anterior fat pad
Anterior humeral line passes through the anterior 3rd of capitellum or fails to intersect with it because of posteriordisplacementof the distalhumerus
Supracondylar Fracture
Tx
Based on the amount of displacement of the fracture
Initial management:
Immobilizationof elbow in long-arm splint
Further management based on grade:
Gartland type I:
Generally managed with long-arm splint < 90° offlexion
Gartland type II:
Majority treated withclosed reduction and surgical pinning
Gartland type III:
Closed reductionand surgical pinning
Clavicle Fractures
general and S/Sx
Commonly fractured bone in children, adolescents, and newborns during childbirth
Usually results from a fall onto the lateral shoulder or a direct blow to the clavicle
Signs & Symptoms
Pain with palpation over the affected area
Pain with abduction of the arm
Tenting of the skin
clavicle fx
grading
Group I: middle third (midshaft) fractures; accounts for 80% of fractures; proximal fragment of often displaced upward
Group II: distal third fractures; accounts for 15% of fractures; usually result from a direct blow to the clavicle; 3 subtypes
Group III: proximal third fractures; accounts for 5% of fractures; often accompanied by intrathoracic injuries (pneumothorax, brachial plexus injury) or sternoclavicular joint damage
clavicle fx
Dx and Tx
Diagnosis
Based on physical examination and plain-film x-rays
AP view and oblique AP view a 15-20˚ cephalic tilt (zanca view) of the affected clavicle
Group II and Group III may require additional imaging studies (CT scan)
Treatment
Sling for comfort for 4-6 weeks
Reduction is not normally needed, even for greatly angulated fractures; if reduction is needed, it is performed by the orthopedist
Significant tenting of the skin requires immediate orthopedic consultation
Antibiotics need to be initiated for open fractures
Group II, type II fractures normally require surgical repair
Rib Fracture
General and S/Sx
Normally result from blunt injury (strong force) to the chest wall
Mild or moderate force (fall) can result in rib fracture(s) in the elderly
Signs & Symptoms
Pain over the fracture site(s) with palpation
Chest wall crepitus over the affected rib(s)
Increased pain with movement of the trunk
Incomplete inspiration → atelectasis and pneumonia
Flail Chest
general
Defined as ≥ 3 contiguousribs that are fractured in ≥ 2 different locations, resulting in a freely moving segment of thechest wallthat is discontinuous from the rest of the thoracic cage
Flail chest is a marker for underlying lung injury (pulmonary contusion)
flail chest
S/Sx
Chest pain
Difficulty breathing
Paradoxical breathing - flail segment will move:
Outward with expiration
Inward with inspiration
flail chest
Dx
Can be made clinically with observation of the paradoxical motion of the flail segment
Plain-film radiographs can confirm rib fractures and often shows underlying pulmonary contusion
Ribs (specify laterality) with CXR
Non-displaced rib fractures are often not visible on plain-film imaging
flail chest
Tx
Hospitalization for ≥ 3 fractures
Humidified oxygen
Operative fixation of ribs
Immobilization should be avoided → ↑ risk for atelectasis and pneumonia
Analgesia (opioid v NSAIDs)
Pulmonary hygiene
Deep breathing every hour while awake (incentive spirometer)
