CHAPTER 190 Fracture Care*

Primary care clinicians are able to manage a wide range of fractures with good outcomes. To do this optimally, however, it is important to have adequate orthopedic training (perhaps on a rotation in residency), as well as supportive orthopedic backup. In fact, primary care clinicians so equipped can manage more complicated fractures, including about a third of fractures requiring reduction. A patient with multiple fractures or open, displaced, intra-articular, or epiphyseal plate fractures should generally be referred to an orthopedic surgeon. Adverse outcomes can be avoided by carefully choosing which fractures primary care clinicians manage, based on their level of training or appropriate consultation. This chapter provides guidelines for the office, urgent care, and emergency center management of fractures by the primary care clinician.

Decisions regarding whether to manage a displaced fracture are often influenced by the state’s malpractice climate, insurance carriers, and premiums. Managing fractures requiring reduction often necessitates a higher level of malpractice coverage and higher premiums. Those clinicians treating fractures, especially fractures that require reduction, must have a good working relationship with an orthopedic surgeon willing to provide informal advice on management and on specific cases. It is ideal to have a relationship with an orthopedist who is able occasionally to examine a patient and return the patient to the referring clinician for follow-up care.

All of the fractures discussed in this chapter can be treated by the primary care clinician, with or without local anesthesia. This chapter is intended to serve as a guide or a basic summary for primary care; it cannot possibly review the management of all fractures. Because the management of fractures in children often differs greatly from that of fractures in adults, children are considered separately.

With all fractures, healing starts when osteoclasts arrive at the fracture site, causing resorption of the dead, soon to be demineralized bone. This resorption results in the fracture line appearing larger in the follow-up radiograph (even in those fractures that are nondisplaced or initially have only hairline cracks). As the fracture heals further, callus forms and the pain and tenderness decrease. However, the radiograph will not show callus and healing until later, when it has mineralized. It is only when mineralization has occurred that the x-ray beam no longer easily penetrates the callus, which results in the image of healing observed on the radiograph.

Box 190-1 lists types of casts. Chapter 186, Ankle and Foot Splinting, Casting, and Taping, and Chapter 187, Cast Immobilization and Upper Extremity Splinting, contain more details on casts than are discussed in this chapter.

Box 190-1 Types of Casts *

Long-arm cast (see Fig. 187-7): Always begins at the level of the proximal palmar crease and ends at the upper two thirds of the humerus. It always holds the elbow in 90 degrees of flexion. It begins as a short-arm cast and is then extended in a second stage.

Short-arm cast (see Fig. 187-4): Always begins at the proximal palmar crease and ends just below the elbow crease.

Short-leg cast (see Fig. 187-5): Always begins at the tips of the toes with the ankle in a neutral position and extends up to just behind the knee, allowing the patient to bend the knee at least 90 degrees without pinching from the cast.

Long-leg cast (see Fig. 187-7F): Always extends from the tips of the toes up to the proximal thigh. A long-leg cast is always a combination of first applying the short-leg cast and then extending it into a long-leg cast as the second stage, just as for a long-arm cast application.

If the knee is in approximately 30 degrees of flexion, crutch walking is easier because the foot is out of the way on the non–weight-bearing side. The 30 degrees of flexion helps control rotation of the tibia and ankle; it also prevents the patient from walking on the cast. Without 30 degrees of flexion, no rotational control is present.

^* See Chapter 187, Cast Immobilization and Upper Extremity Splinting.

Equipment

See the discussions of equipment in Chapter 186, Ankle and Foot Splinting, Casting, and Taping, and Chapter 187, Cast Immobilization and Upper Extremity Splinting.

Terminology

Open fracture: This fracture communicates through a hole in the skin; therefore, by definition, an open fracture is contaminated and is more likely to become infected, especially if the hole is greater than 1 cm in diameter. Open fractures should almost always be referred to an orthopedic surgeon. (Previously, the term compound fracture was used to describe an open fracture.)

Closed fracture: This fracture is not openly communicating through a hole in the skin. The vast majority of fractures are closed, and the skin is unbroken.

Torus fracture: In this fracture only one of the cortices is buckled.

Greenstick fracture: A greenstick fracture is a level worse than a torus fracture. It involves an actual crack or disruption of one cortex and buckling of the opposite cortex. This fracture is so named because the bony deformation is much like that seen after cracking a green tree twig in springtime: the tension side of the bent twig cracks, whereas the compression side (i.e., the concave side) merely buckles.

Comminuted fracture: In this fracture the bone is in more than two pieces. Often an additional piece, which is small and shaped like a butterfly and therefore named a butterfly fragment, is found at the fracture site.

Fracture dislocation: A joint is dislocated and associated with a bony fracture on one or both sides of the joint.

Intra-articular fracture: This fracture extends into the joint or articular surface. If an intra-articular fracture is displaced, the patient should be referred to an orthopedic surgeon.

Delayed union: Delayed union occurs when a fracture is not healed after a time interval that is twice the normal healing time. For example, a fracture of the radius would be considered a delayed union if it has not healed in 4 months because it has an expected healing time of 2 months.

Nonunion: The bone has not united after three times the normal healing time. For example, a distal radius fracture is expected to heal completely in 2 months. If it has not healed in three times that amount, or 6 months, it is considered a nonunion fracture.

Atrophic nonunion: A bone end near the fracture becomes pointed like a partially consumed peppermint stick or icicle without any sign of new bone formation.

Hypertrophic nonunion: The bone end forms new bone even though it is not united.

Malunion: A fracture has united with unacceptable angulation, rotation, or shortening.

Fractures in Adults

Cervical Spine Fracture

The possibility of a cervical spine fracture being unstable with associated spinal cord complications should always be considered (in fact, most are unstable). The exceptions would be a certain spinous process fracture (clay shoveler’s fracture) or a simple anterior wedge fracture (defined as <25% loss of vertebral body height and no subluxation on dynamic flexion-extension radiographs of the cervical spine). The clay shoveler’s fracture is an avulsion of the tip of the spinous process of C6 or C7 due to stress on the interspinous ligaments. These cervical fractures require nothing more than a soft cervical collar and symptomatic management.

All patients with a suspected cervical spine fracture should have a three-view series of cervical spine radiographs: cross-table lateral, anteroposterior (AP), and open-mouth odontoid views. In most cases, the lateral view should be taken first to rule out an occult fracture before the neck is moved. Overall, this view provides 90% of the information regarding the stability of the spine. The radiologist, neurosurgeon, or orthopedist can review the radiographs to exclude any associated problems. It should be noted that even minor fractures seen on plain radiographs may be associated with significant ligamentous injuries that render the cervical spine unstable; consultation with a neurosurgeon or orthopedist is helpful.

Thoracolumbar Spine Fractures

A thoracolumbar spine fracture can generally be treated with symptomatic management, brief (24 to 48 hours) bed rest with serial neurologic monitoring, followed by back support (thoracolumbosacral orthosis [TLSO]) and rehabilitative exercises. Exceptions include evidence of instability such as loss of greater than 50% of the anterior vertebral height (compared with posterior vertebral body height), presence of more than 20 degrees of angulation, an increased space between the spinous processes, and disruption of the facet joints; these patients should generally be referred. Burst fractures or fractures associated with any sign of neurologic injury should also be referred for orthopedic or neurosurgical consultation to rule out instability (which may require surgical stabilization). An exception to the use of a TLSO is a compression fracture occurring in an osteoporotic patient; in such cases, a TLSO is usually unnecessary and may impair return to function in the elderly.

Fractures of the upper thoracic spine (T1 to T9) tend to be more stable because of attachments of the rib cage, which in turn are further stabilized at the sternum. Fractures of L2 to L5 tend to be more stable because of the larger vertebral bodies; fractures of L5 and S1 tend to be unstable because of the high-energy forces required to cause injury at this level. Transverse process fractures, usually at L2, L3, or L4, and spinous process fractures are usually benign and do not affect spine stability. With a transverse or spinous process fracture in the general region of the kidneys, the possibility of a renal contusion should be considered.

For possible thoracolumbar spine fractures, radiographs should include AP, lateral, and oblique views of the entire thoracolumbar spine (patients often have fractures at more than one level). When managing a compression fracture, serial radiographs should be obtained at 3, 6, and 12 weeks to rule out a progressive kyphotic deformity (>20 degrees of angulation). Computed tomography (CT) scanning is particularly helpful in diagnosing multiple or occult fractures or bony impingement on the spinal canal. Magnetic resonance imaging (MRI) is useful for evaluating soft tissue injury. When managing these fractures, an accompanying ileus is fairly common. Always consider radiographs of the lumbar spine in a patient who has a calcaneal fracture because the axial loading associated with such an injury is often associated with a lumbar spine fracture.

Pelvic Fractures

Pelvic fractures managed by primary care clinicians tend to occur in osteoporotic older patients due to a fall. Otherwise, pelvic fractures are usually the result of significant trauma in a motor vehicle accident or a fall from a considerable height. Most fractures of the pelvis are diagnosed on the AP view. Additional views to assess the pelvis include inlet, outlet, and oblique views of the acetabulum. If there is concern for acetabular involvement, obturator (45 degrees of internal rotation) and iliac (45 degrees of external rotation) oblique views should be obtained; a radiologist or orthopedist will usually be able to determine from these views whether any question remains of acetabular involvement. If the acetabulum is involved, the patient should generally be referred to an orthopedist. If comminution is present, CT can be used for further delineation. Orthopedic referral should also be considered if the pelvic ring is unstable. However, there must be two breaks in the pelvic ring, either from two fractures or a fracture plus a joint dislocation (usually the sacroiliac joint), for a pelvic fracture to be unstable. Fractures external to the pelvic ring are generally considered stable (Fig. 190-1).

Figure 190-1 Stable pelvic fractures. A, Nonsdisplaced ramus fractures. B, Fracture of the pelvis not involving the ring (top). Stable, minimally displaced fracture of the ring (bottom).

If the pelvic fracture is considered stable, the patient can be treated with bed rest, analgesics, walking as tolerated, or full weight bearing with a walker. The pubic and ischial rami function only as tie rods for the anterior portions of the pelvis; they are not weight bearing. The typical older woman who falls and breaks her pelvis has a pubic or ischial ramus fracture only (see Fig. 190-1) and does not require either surgical intervention or bed rest. Otherwise, the length of bed rest is variable, usually from 2 to 4 weeks; the patient may sit as tolerated. During bed rest, gentle range of motion exercises of the lower extremities should be performed, especially in the elderly. Although walking may be uncomfortable, explain to the patient that it is not dangerous or harmful.

If the pelvic fracture occurs in an individual younger than 50 years of age or one involved in a motor vehicle accident, be prepared to resuscitate the patient because hemorrhagic shock is the major cause of death. Consider the possibility of bladder, urethral, or external genitalia injury, especially with anterior pelvic fractures and especially in men. Always palpate the sacroiliac joint to ensure that it is nontender and therefore not involved in the injury.

Intertrochanteric Femur Fracture

The intertrochanteric femur fracture (Fig. 190-2) is the most common type of hip fracture. Occurring between the greater and lesser trochanter of the proximal femur, this fracture does not involve the hip joint itself; it is an extra-articular, extracapsular fracture. The patient typically presents with a markedly shortened and externally rotated leg, painful with any movement of the hip. An intertrochanteric fracture usually results from the patient tripping over a carpet, pet, or step or slipping and falling; the force of the direct fall onto the intertrochanteric area causes the fracture. This scenario is entirely different from the femoral neck stress fracture discussed next. Repair of the intertrochanteric fracture requires hip pinning with a compression screw. It may require open reduction with use of a bone plate device to achieve near-anatomic alignment. Without repair, the intertrochanteric fracture, even if nondisplaced, is at high risk for displacement with such minor activities as rolling over or moving in bed. Therefore, if possible, these patients should be referred to an orthopedist for surgical repair. In the nonambulatory patient, such as the nursing home patient, nonoperative treatment may be a safer and less costly alternative. The patient should be managed symptomatically; Buck’s traction can be used intermittently to reduce pain. The patient should be mobilized to a sitting position within 2 to 3 days. Nonoperative treatment for the ambulatory patient is a rare possibility; it is beyond the scope of this chapter.

Figure 190-2 Fractures of the proximal femur: Neck (a); intertrochanteric (b); subtrochanteric (c).

Femoral Neck Fracture

Fracture of the femoral neck (see Fig. 190-2) is the second most common type of hip fracture. For a younger person to sustain a femoral neck fracture from trauma takes signficant force; therefore, most of these fractures occur in older osteoporotic patients, often while just walking in the home. The hip suddenly gives way, and the patient falls to the floor; no history of tripping over a carpet, pet, or step is usually reported and the patient does not know the reason for the fall. In most cases, an osteoporotic femoral neck fracture is actually a stress fracture, which ultimately becomes complete. As the fracture completes itself, it results in the instability that causes the patient to fall. Most of these fractures are displaced; therefore, appropriate treatment is prosthetic replacement (one half of a total hip). Occasionally, these fractures are nondisplaced and can be treated with pinning. Because the femoral neck (most of it) is intracapsular, the greater the displacement, the greater the risk of vascular compromise. Because of this tenuous blood supply, all femoral neck fractures should be monitored for the development of avascular necrosis, even if a prosthesis is placed.

If a patient does not have a history of falling but complains of pain in the groin aggravated by walking and weight bearing, rule out hip osteoarthritis with a weight-bearing radiograph. Always be certain to order a true lateral radiograph of the hip because it will often show a fracture not visible on the plain AP or “frog leg” AP view. If the hip joint is free of osteoarthritic findings, a diagnosis of impending stress fracture should be considered. In some patients, the fracture is not visible on the radiograph but can be observed on limited MRI. MRI is now considered the standard of care because it is more sensitive and specific than either a bone or CT scan for diagnosing femoral neck stress fractures. Nonathletes with nondisplaced stress fractures in progress demonstrated by bone scan or MRI can be treated with a walker and no weight bearing on the involved side. This treatment often allows the fracture to heal completely and prevents surgery.

Femoral neck stress fractures can also occur in athletes, and inguinal or anterior groin pain is the most frequent symptom. If the diagnosis is delayed, night pain can occur. On physical examination, discomfort is noted at the extremes of internal and external rotation, especially internal rotation. Compression-type stress fractures occur on the inferior medial border of the femoral neck and are considered more stable; tension-type stress fractures occur on the superior lateral border, are less stable, and are more prone to dislocate. Patients with an overt fracture line should be referred to an orthopedist. Conservative treatment consists of modified bed rest followed by assisted crutch-walking as tolerated until healing is seen (usually 6 weeks); cross-training with cycling or swimming will be helpful for maintaining fitness. Serial radiographs should be obtained every 1 to 2 weeks for the first month or at any time the patient stops improving; if sclerosis extends through both cortices or a crack develops, the patient should be referred. If the patient fails to heal with non-weight-bearing, he or she should be referred to an orthopedist. Otherwise, after 6 weeks, weight-bearing exercise can be resumed to preinjury levels over a span of 6 to 8 weeks; the patient should be able to walk a mile without pain before any running is allowed.

Femoral Shaft Fracture

Femoral shaft stress fractures can also occur in athletes. Lacking a history of trauma, the athlete often presents with vague thigh pain, diffuse tenderness, and a suspected quadriceps strain. These patients frequently wait 4 to 6 weeks following the onset of symptoms before seeking care; persistent, worsening symptoms finally bring them in. Fortunately, most femoral shaft stress fractures do not progress to complete fractures. Conservative care consists of relative rest with a switch to non-weight-bearing activities such as swimming or cycling for 6 to 8 weeks. Serial radiographs should be obtained and results managed as for a femoral neck stress fracture. Return to full activity can usually be anticipated after 3 to 4 months.

Other than stable stress fractures, femoral shaft fractures should always be referred for surgical stabilization. These fractures are at high risk for fat embolism and neurovascular problems. A distal femur fracture, which is often intra-articular (extending into the knee joint), should usually undergo surgery to stabilize the fracture, even if the fracture is nondisplaced.

Patellar Fractures

If the articular surface is smooth and the quadriceps mechanism intact, a nondisplaced patellar fracture (Fig. 190-3), whether comminuted or not, can be treated with a cylinder (from above malleoli to groin), full weight-bearing walking cast or with a knee immobilizer (in a reliable patient), crutches, and 10% partial weight-bearing activities. Consider referring severely comminuted fractures or fractures with more than 3 mm separation or more than 2 mm articular step-off to an orthopedist. Otherwise, a follow-up clinical examination is performed and AP and lateral radiographs assessed 3 weeks after initial treatment. If no displacement exists and tenderness with palpation is resolved, then gentle non-weight-bearing range of motion exercises can be started in an arc of 0 to 45 degrees. Another radiograph should be obtained 6 weeks after treatment; at this point, the fracture should be solidly healed and point tenderness over the patella resolved. Active and passive range of motion activities can now be initiated in therapy. During the healing phase, the patient should be encouraged to carry out quadriceps and hamstring isometric and straight-leg raising exercises to maintain muscle function and tone.

Figure 190-3 Classification of patellar fractures. A, Nondisplaced transverse. B, Displaced transverse. C, Upper or lower pole. D, Comminuted. E, Vertical.

Marginal vertical fractures that are nondisplaced do not have to be immobilized. They can be treated with reduced activity for 4 to 6 weeks followed by progressive range of motion and strengthening exercises.

Tibial Plateau Fractures

The clinician should be certain that a tibial plateau fracture is not depressed or displaced, especially if it extends into the joint surface. Lateral, AP, and internal and external oblique radiographs should be obtained. A tunnel (notch) view is helpful for visualizing the intercondylar eminence. Tomograms are the only method to exclude displacement. CT will help delineate the extent of articular involvement and fracture displacement; MRI also provides this information and can detect ligamentous and meniscal injuries. If any depression or displacement has occurred, the patient must be referred; fractures associated with ligamentous or meniscal injury should also be referred. These referrals should generally occur within 24 to 48 hours.

If the fracture is extra-articularly displaced (intra-articularly nondisplaced), it can be treated with crutches, non-weight-bearing activities for 3 months, and gentle range of motion activities. Otherwise, the patient should remain non-weight-bearing for 4 to 6 weeks, until there is radiographic evidence of healing, and can then progress to partial weight bearing with crutches. Crutches should be used until solid union of the fracture is documented. These fractures need to be watched carefully with clinical examination and radiographs at 2-week intervals for the first month to be certain there is no displacement, which can occur with motion of the knee joint. Be certain to document the strength of the peroneal nerve.

Tibial Shaft Fractures

Tibial shaft fractures (Fig. 190-4) can be treated with a long-leg cast with the knee in 0 to 5 degrees of flexion and the ankle in neutral position (90 degrees). The patient can bear weight with this cast, and ambulation should be encouraged as soon as possible (as long as there is no risk for compartment syndrome [see Chapter 188, Compartment Syndrome Evaluation], which can occur at up to 10 days). As it turns out, most patients are not able to bear significant weight, due to discomfort, for 1 to 2 weeks.

Figure 190-4 Tibial shaft fractures. A, Transverse or short oblique. B, Small butterfly fragment. C, Large butterfly fragment. D, Segmental comminution. E, Spiral. F, Proximal one fourth transverse or oblique. G, Distal one fourth transverse or oblique. The fracture in A is usually stable. The stability of the fractures shown in B and C is dependent on the size of the butterfly fragment. The fracture shown in D is usually unstable. The fractures shown in E–G are stable but difficult to control.

Proximal shaft fractures are often due to high-energy forces, but distal fractures are usually the result of low-energy injuries; this concept is important to consider during management. There should be less than 5 mm of displacement in both the AP and mediolateral planes; otherwise, the patient should be referred. If any angulation of the tibial shaft fracture has occurred, a goniometer must be used to assess the amount. Angulation up to 10 degrees in the AP radiograph and up to 5 degrees in the mediolateral plane is acceptable. Angulation greater than these amounts requires correction by wedging the cast; these patients should be referred.

If less than 50% bone surface contact between fracture fragments is observed in the AP or lateral views, then the patient should be referred to an orthopedic surgeon. Degree of rotation should be determined by the amount of discrepancy between transverse widths of the proximal and distal fragments; greater than 10 degrees of rotation should also be referred. Shortening greater than 2 cm is not acceptable and requires referral. If any doubt remains about the amount of overlap (which causes shortening), a bone length measurement radiograph can be obtained for the radiologist to compare the length of one tibia with the other.

For tibial fractures in which the fibula is not broken, very little chance exists of the tibia becoming unacceptably shortened because the fibula will splint the soft tissue at an appropriate length. If the fibula is broken in addition to the tibia, a higher incidence of shortening of the tibia exists as a result of unopposed muscle contraction. This is especially true in an oblique angle fracture; the oblique angle allows sliding of the fracture into a shortened position. If the fracture is transverse, then this sliding shortening cannot occur. Nevertheless, combined tibia–fibular fractures are frequently due to high-impact forces, are at high risk for compartment syndrome, and are rarely nondisplaced; these patients are frequently referred.

If the fracture is satisfactory in alignment and length, then a long-leg cast for a period of 4 to 6 weeks is appropriate. For the initial cast, plaster is usually easier to mold; fiberglass reinforcement can then be applied in a few days if this cast is left in place. The cast will usually need to be changed in 2 to 3 weeks because of loosening as the swelling decreases. After 4 to 6 weeks, the cast can be cut down to a short-leg walking cast or a walking cast brace for an additional 10 to 14 weeks, until clinically healed. To verify clinical healing, there should be minimal tenderness over the fracture site and no motion or pain with bending stress in any direction.

Tibial fractures are notorious for developing compartment syndrome (see Chapter 188, Compartment Syndrome Evaluation) when any significant soft tissue trauma has occurred. If the tibial fracture is the result of a fall from a height greater than 6 feet or the result of a high-velocity injury such as in an automobile accident, be very cautious about the possibility of compartment syndrome. Be certain that the patient elevates the leg at home so that the calf is 2 feet higher than the heart at all times, except when going to the bathroom, for 1 week. Explain to the patient that the heart is the pump, and that the fluid from the leg needs to drain toward the pump, which requires the fluid in the leg to be elevated higher than the pump. Seat cushions from the couch stacked three high under the calf can help achieve this elevation. The patient’s chest must be flat, although pillows can be placed under the head to facilitate reading and eating. Sitting in a recliner, however, does not provide adequate elevation because the chest is only at the level of the calf.

Patients at risk for compartment syndrome may use their crutches to go to the bathroom, placing no weight on the injured side. They should return to the bed, couch, or floor, lie down, and resume elevation of the leg as soon as possible. If there is loss of fine-touch sensation or two-point discrimination, distention and swelling of the calf, pain with passive motion of muscle groups (especially extension of the great toe), progressive pain, or pain not relieved by oral pain medication such as narcotics, then emergent testing should be performed or referral made to rule out compartment syndrome (see Chapter 188, Compartment Syndrome Evaluation). The peak time for compartment syndrome after a tibial fracture is on the third day after the injury.

Tibial stress fractures are one of the most common stress fractures in young athletes and military recruits. They occur more commonly at the junction of the middle and distal thirds of the tibia in runners, in the middle third in ballet dancers, and in the proximal third in military recruits. Symptoms are usually insidious in onset, increase with physical activity, and may become severe enough to persist for hours after activity or even at night. There is usually pain with palpation but minimal swelling at the site of tenderness. However, pain can often be elicited at the site by applying a tuning fork or by percussing the tibia away from the site. Radiographs are frequently negative for 2 to 4 weeks after the onset of symptoms; a triple-phase bone scan can be helpful if a stress fracture is strongly suspected. Most tibial stress fractures are treated with elimination of impact activity for 4 to 6 weeks, cross-training, and crutches as needed for pain. Radiographs should be taken monthly to document healing.

Radiographs may demonstrate the “dreaded black line” fracture, which is an anterior midshaft tibial stress fracture associated with poor healing, a risk of nonunion, and risk of recurrence. These fractures typically take 6 to 12 months to heal; patients must refrain from impact loading activities until they are pain-free and there is complete radiographic healing.