University of Iowa Family Practice Handbook, Fourth Edition, Chapter 16

Orthopedics: Fractures

1. Terms.
   1. Closed fracture. Fracture that does not communicate with the outside.
   2. Open fracture. Fracture that communicates with the external environment.
   3. Comminuted fracture. Consisting of three or more fragments.
   4. Avulsion fracture. Fragment of bone pulled from its normal position by a muscular contraction or resistance of a ligament.
   5. Greenstick fracture. Incomplete, angulated fracture of a long bone, particularly in children.
   6. Torus fracture. Compression of the bone without cortical disruption. Seen especially in the forearms of children.
2. Epiphyseal Plate Fractures. Described using the Salter and Harris classification (Figure 16-2).
   1. Salter I (approximately 6%).
      1. Separation of the epiphysis from the metaphysis without evidence of a metaphyseal fragment.
      2. Usually the result of a shearing force, can be associated with birth injury.
      3. Most common in infants and young children.
      4. High index of suspicion is necessary because spontaneous reduction can occur.
      5. Prognosis is excellent because epiphyseal blood supply is usually intact and growing cells of epiphyseal plate are undisturbed.
   2. Salter II (approximately 75%).
      1. Fracture extends transversely through the epiphyseal plate and then out through the metaphysis on the side opposite the fracture initiation resulting in a triangular metaphyseal fragment.
      2. Most frequent in children over 10 years of age.
      3. Usually treated with closed reduction.
      4. Prognosis is excellent because the blood supply is almost always intact.
   3. Salter III (8%).
      1. Intraarticular fracture that extends from the joint surface across the epiphysis to the epiphyseal plate and out to the periphery.
      2. Commonly involves the lower tibial epiphysis.
      3. Caused by an intraarticular shearing force.
      4. Often requires open reduction.
      5. Prognosis is good if the blood supply is intact and reduction is maintained.
   4. Salter IV (10%).
      1. Intraarticular fracture consisting of a vertical fracture through the epiphysis that crosses the epiphyseal plate and leaves through a portion of the metaphysis.
      2. Frequently involves lateral condyle of humerus.
      3. Treated with anatomic reduction and internal fixation.
      4. Prognosis is poor unless reduction is maintained.
   5. Salter V (1%).
      1. Results from a crush injury through the epiphysis to a portion of the epiphyseal plate.
      2. Usually occurs in a joint that has only one plane of movement.
      3. Most commonly seen in the knee and ankle.
      4. Initial radiographs tend to be normal and so must suspect this fracture from the mechanism of injury.
      5. Results are poor with premature cessation of growth.
      6. Nontraumatic events causing a Salter V type of injury are metaphyseal osteomyelitis and epiphyseal aseptic necrosis.
      7. Salter V can occur in conjunction with Salter I, II, and III fractures and not be recognized until growth arrest occurs.
      8. Treat with 3 weeks of no weight bearing.
3. Repair.
   1. A good rule of thumb is that most bones join in 6 to 8 weeks; lower limb bones may take longer; fractures in children may take less time.
4. Complications.
   1. Immediate complications, within the first few hours, include hemorrhage, damage to arteries, and damage to surrounding soft tissues.
   2. Early complications, within the first few weeks, include wound infection, fat embolism, shock lung, chest infection, DIC, and exacerbation of general illness. May also have compartment syndrome, with the anterior compartment of the leg most common (see Chapter 2 for details of compartment syndrome).
   3. Late complications, months and years later, include deformity, osteoarthritis of adjacent or distant joints, aseptic necrosis, traumatic chondromalacia, and reflex sympathetic dystrophy.
   4. If a patient complains of pain after casting, assume a tight cast and possible compartment syndrome. Bivalve the cast including all layers of cotton, stockinet, etc. and wrap with ACE wrap. Consider recasting in several days.
5. Management of Some Specific Fractures.
   1. Fracture of radial head. Usually caused by a fall onto an outstretched hand. Patients are reluctant to pronate the hand or to flex the elbow beyond 90 degrees. The only roentgenographic evidence may be an anterior or posterior fat pad sign. The posterior fat pad is more specific but less sensitive. Management of nondisplaced fractures in those who can fully extend the elbow includes a sling and posterior elbow splint for 1 to 2 weeks with range-of-motion exercises after 1 week. Continue in sling for another week and do follow-up radiograph to document that no displacement has occurred with mobilization. If there is displacement of the radial head, the patient should be referred to an orthopedist for operative repair.
   2. Radial fractures.
      1. In children, the most common injury is the torus (buckle) fracture, which occurs with a fall onto an outstretched hand. Radiographic findings may show only a slight cortical disruption on the lateral film. Treatment is a short arm cast for 3 weeks.
      2. In adults, the most common radial fracture is the Colles’ fracture, which is extra-articular and occurs 2.5 to 3 cm proximal to the articular surface of the distal radius. This fracture occurs with the hand dorsiflexed; the distal fracture segment is angulated dorsally and causes a "silver-fork" deformity. Reduction by traction and manipulation can be performed. After reducing the fracture, a plaster short-arm cast is applied for 5 to 8 weeks. If nondisplaced, casting for 6 weeks without reduction is indicated.
   3. Metacarpal fractures. A boxer’s fracture is a fracture of the distal neck of the fifth metacarpal and is generally the result of punching something with a closed fist (generally a wall or refrigerator). Tenderness is localized to the injured metacarpal bone. Radiographs reveal a fracture of the involved metacarpal or subluxation at the carpometacarpal joint. Nondisplaced fractures of the base of the metacarpals are treated with immobilization in a short arm cast. Displaced fractures are reduced by traction with local pressure over the prominent proximal end of the distal metacarpal fracture. A follow-up radiograph is necessary within 7 days. If any instability is noted after reduction or the fracture is comminuted, the patient should be referred to an orthopedist for open reduction and internal fixation.
   4. Fractured finger.
      1. Distal tip fractures are usually crush injuries to the tip of the finger. Protective splinting of the tip for several weeks is usually satisfactory.
      2. Middle and proximal phalangeal fractures should be examined for evidence of angulation (by roentgenography) or rotation (by clinical examination), which require reduction. Nondisplaced extraarticular fractures can be managed by 1 to 2 weeks of immobilization followed by dynamic splinting with buddy taping to the adjacent finger. Large intra-articular or displaced fractures are usually unstable and require orthopedic referral.
      3. Small (<25%) avulsion fractures of the middle phalangeal base occur with a hyperextension injury. These injuries are managed by 2 to 3 weeks of immobilization with up to 15 degrees of flexion at the PIP joint, followed by buddy taping for 3 to 6 weeks.

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See related Provider Topics Bones, Joints and Muscles, Fractures or Injuries and Wounds.

See related Patient Topics Bones, Joints and Muscles, Fractures or Injuries and Wounds.

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