Common Fractures Flashcards by Leslie Mancini

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

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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

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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)

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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

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Left: Boxer’s fracture with angulation
Right: fight bite

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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

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Scaphoid Fractures

Most commonly injured carpal bone
Usually results from wrist hyperextension injuries (fall onto an outstretched hand (FOOSH))

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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

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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

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scaphoid fx

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

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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

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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

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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

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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

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

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

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: Immobilization of elbow in long-arm splint Further management based on grade: Gartland type I: Generally managed with long-arm splint < 90° of flexion Gartland type II: Majority treated with closed reduction and surgical pinning Gartland type III: Closed reduction and 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 contiguous ribs that are fractured in ≥ 2 different locations, resulting in a freely moving segment of the chest wall that 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)**