Fracture Management Series Part 3
Serena:
Welcome to the latest instalment of the Rural Health Webinar Series. My name is Serena, and I will be hosting tonight’s webinar. Tonight’s webinar forms part three of the Fracture Management Series. It will provide rural and remote GPs with information on how to identify, manage and treat less common upper and lower limb fractures.
Tonight’s webinar is facilitated by Dr John Adie and Andrew May. John is the RACGP Special Interest Group Chair for Urgent and Emergency Presentations to Primary Care, and Australian Convener for the Royal New Zealand College of Urgent Care. He has been a rural GP in the Barossa Valley and led the pilot site that the Queensland Primary Care Fracture Clinic was the subject of.
We would like to begin tonight’s webinar by acknowledging the traditional owners of the lands that we are coming from and the land on which the event is being broadcast. I would like to pay our respects to their Elders past, present and emerging, and would also like to acknowledge any Aboriginal or Torres Strait Islander people who are joining us this evening.
And just before we start, there are a few housekeeping things to cover. Participants are set on mute to ensure that the webinar is not disrupted by background noise, but we encourage you all to use the chat function or Q and A function to ask questions. When using the chat function, we do ask that you address your questions and comments to all panellists and attendees rather than just the panellists, so that everyone can see your questions and comments. And finally, the webinar has been accredited for one hour of CPD educational activities. To be eligible, you must be present for the duration of the webinar. We also kindly ask that you complete the short evaluation at the end of the webinar. It should only take a few minutes to complete and will help us improve the format and content of future webinars.
By the end of the webinar, participants will be able to identify the common fractures able to be managed in a general practice setting. Proximal humerus, radial head and neck, carpal, tarsal and patella. Identify resources commonly used for the management of common upper and lower limb fractures. Apply appropriate management strategies for common upper and lower limb fractures, and identify opportunities to improve skills in the management of common upper and lower limb fractures. But for now, I will hand over to our facilitator for this evening, Dr John Adie.
John:
Thanks, Serena, and thanks so much to RACGP for getting Andrew and I back for this third instalment of the fracture management series. During my training as an urgent care physician and GP in New Zealand, we managed fractures regularly. In our urgent care centres, we would see a lot of the fractures that we have talked about in sessions one and two, and the fractures that we manage today. We were lucky enough to have an orthopaedic surgeon on site every week, so that after the expected time of fracture management healing had settled, or had past, and the fracture had not settled, we were able to refer the patient to the orthopaedic surgeon or ask for advice on difficult fractures. This was followed by some time in the Barossa Valley and the Royal Adelaide Emergency Department, then most recently in the Sunshine Coast over the last nine years, where the Sunshine Coast Hospital and health service asked us to run a fracture clinic. The fracture clinic was analysed by Queensland Health, and took 23% of went to the hospital fracture clinic. Subsequently, the model was copied around Queensland. The first two sessions covered seven of the most common fractures that was 80% of what was referred to us. The session today what we will be looking at is five fractures that make up the last 20% of what was sent to us at the fracture clinic.
In recent years, I have finished research on urgent care, and it is exciting to see this fracture management model being used around the country, because the fractures and the type of treatment we are talking about today, I believe belongs in general practice, and I think us as general practitioners can help the health system and patients a lot by taking on management of some of these fractures that we will be talking about today.
So, a quick recap on the last two sessions, where we look at resources. Very helpful resources for managing fractures. Firstly, Orthobullets. It is a free online learning tool and it gives you the answers to managing fractures and to a lot of the questions that you will ask.
Here is our own Royal Children’s Hospital in Melbourne guidelines. I love this website. You can see here, there are fracture guidelines for Emergency Departments. So when the patient comes in. Also, for fracture clinic and there is educational resources for families. Radiopaedia is absolutely fantastic, and if you are ever preparing talks, it has a creative commons licence, so you can use the x-rays from there in your presentation. Here is a couple of books that I think it is important to have on site for reference. There is the McRae’s Orthopaedic Trauma and the Practical Fracture Treatment books. They are very helpful as well.
A couple of basics. We have talked about this before, so I will just be brief on these. This is fracture healing. There is three common phases. The first is the inflammatory phase which is hours to days, and that is when you cytokines, prostaglandins, growth factors, form fibrovascular tissue and the fracture starts to set. So, you have usually got 7 to 10 days to get the fracture management right before it sets and it has to be re-broken. Then there is the reparative phase that can take days to weeks. This leads to clinical healing. And lastly, the remodelling phase, over months to years. And you can see over on the right a proximal humerus fracture. After two years, there is still evidence of healing.
I have also managed patients or seen patients obviously when they come in, day 7 to 10, and when the fracture management episode heals and finishes. Sometimes at the end of that, the fracture is not clinically healed, but still tender, I give them a couple of weeks and then splint or plaster, and then see them again. It is always important to document an examination of the joint above and below, as well as neurovascular status. You will see from a number of injuries today and what they are associated with, that if you always do this, you will be less likely to miss important parts of the presentation. Always be aware of Salter Harris 3-5 and open fractures, I would always involve an orthopaedic surgeon in the management of these fractures.
And ideal management involves sending people to physio. So in New Zealand, we have excellent compensation, which means a very minimal gap for patients, whereas over here, physio is often cost prohibitive. So I will often go onto websites that I trust with pdf resources and I hand them out to the patient. I still have a protractor, pencil and a ruler to help me manage the angles. So a lot of what we are talking about today is based on using angles and measurements. These days, we get online x-rays and you can use the tools there to work out displacement, and that is very helpful. But unfortunately, if you do get it on your phone, you cannot do that. If it looks munted, call ortho. When I mentioned that before, I got a question, what does munted look like? Munted looks really abnormal and there will some examples today of fractures that just do not look right, and if you are not sure, get someone to help you. There is about 4% of the time, in a study, that emergency physicians would miss fractures, so it is one of those things that happens. So what I say to people when I am working and the radiologist is not necessarily on call, I cannot see a fracture, but 4% of the time, fractures are missed, so I will be calling you in the next day or two if that is the case, so they do not get a surprise if you call them. Always get an AP and a lateral, that is really important.
If there is a significant chance of a bad outcome, ask the advice of an orthopaedic surgeon. So we will be talking today about the tarsal fractures, especially the talus and the calcaneus and I will often send those to the orthopaedic surgeon, even though they might not be displaced, because there is a high risk of bad outcome. I text a lot of films and injuries to orthopaedic surgeons these days, especially when working around the country in urgent care. I am careful that I document the patient’s consent, and not have identifying features of the patients on the films.
There is a difference between clinically and radiologically healed fractures. A study done on long bone fractures of orthopaedic surgeons found that 62% used both clinical and radiological criteria, 37% used radiological criteria, and 1% of people used the clinical criteria only. So, it is subjective. There is not really any gold standard. But often with the distal limb fractures, especially the ones we will be talking about today, usually if there is no tenderness, it is clinically healed. The unwritten deal we had with our local orthopaedic surgeons was that if a fracture was not healed in 10 weeks, we would refer the patient to the orthopaedic surgeon, or at least have their involvement.
So, we are going to be talking about five different types of fractures tonight. The fist in the upper limb is the proximal humerus fracture. So predominantly female, 5% of all fractures. So, these fractures do present. The most common is the two part surgical fracture, and the risk factors are diabetes and epilepsy. A little bit of anatomy, using the Neer classification. So you can see here, with my arrow, the anatomical neck which is the old growth plate. Then there is the surgical neck, which is the most common area for fractures because it is weakened. So it is much more involved than the anatomical neck. There are muscles attached in the greater tubercle, so up here in 1, and you will remember from the anatomy books, say Grace before tea, supraspinatus, infraspinatus, and teres minor, and subscapularis attaches to the lesser tubercle here.
So with the Neer classification, it is a four part system, and it has prognostic and therapeutic implications. So the one part, which is non-displaced and non-angulated, these are the ones that we are looking to manage. And the four parts are the greater tuberosity, the lesser tuberosity, humeral head and the humeral shaft. And the classification is according to how much one or more of the parts is displaced. So if there is separation of more than 1 cm, or angulation of more than 45 degrees, then it is considered displaced. An 80% of the proximal humeral fractures are one part, and these are the ones that we will be looking to manage in general practice.
A little bit of a reminder of basically neurovascular status. It is important to check for this and be reminded to check neurovascular status. When we are talking about the neurological status, we are talking about the axillary nerve, because especially in proximal humeral fractures, that can cause neuropraxia. Commonest mechanism of injury is the fall on the outstretched hand. And when I am examining patients with proximal humeral fractures, will be looking for extensive bruising, damage to the anterior and posterior circumflex humeral arteries and the axillary nerve neuropraxia, which is just right up here on the deltoid. That is where the supply is.
So, a few fractures to refer. Here is a comminuted fracture of the greater and lesser tuberosities. There is displacement more than 1 cm, so I will be referring this patient for an orthopaedic opinion.
Here is another fracture of the humeral head. It is comminuted and involves the greater tuberosity and also the surgical neck, so here and here, and there is superior displacement of the humeral shaft. So, because there is more than 1 cm displacement and there is numerous parts to the fracture, I will be referring those. So remembering that 80% will be one part fractures.
Here is a combination three part fracture, with displacement here involving the surgical neck, the greater tubercle and the humeral head, and there is more than 1 cm displacement. So, these are obviously ones that we are going to refer.
And here is a Salter-Harris 2 fracture, involving the right humerus proximally and it has got 1.2 cm displacement, so again, it is above our 1 cm threshold, so we are going to ask an orthopaedic surgeon to look at that.
The ones we are going to look at to manage ourselves are the ones that are minimally displaced, basically surgical and anatomical neck there. More likely to be the surgical one. Surgical neck articular segment of less than 1 cm and less than 45 degrees. If the greater tuberosity is involved and it is displaced less than 5 mm, we are going to look at managing that, and low fracture complexity. So, if it is a one part fracture, I am happy to manage those, otherwise I am going to ask the advice of an orthopaedic surgeon.
And here is a fracture here through the greater tubercle of the proximal humerus, less than 5 mm displacement there. If I was worried about a fracture of the surgical neck, I might get a CT to see if there was more than a two part fracture.
So what I would normally do with managing proximal humeral fractures in week one and two, I would use a sling, or better, a collar and cuff, which Andrew will show us after this, under the clothes, so under my shirt, and it protects the arm from rotational stresses. After two weeks, what I would do is, I would wear the collar and cuff outside my clothes, and three or four times a day, I would do some exercises, and that would be to reduce the chance of a frozen shoulder. So the exercises that I would encourage people to do, is the flexion and extension exercises. I will just stand up a little bit here. Abduction, adduction, and basically rocking movements out of the sling. Do that four times a day, three reps of 10, as the patient tolerates it, just to decrease the chance of a frozen shoulder. After week four, I would use the collar and cuff outside the person’s clothes. At week six, then I would send the person to physiotherapy. Week eight to 12, it is strengthening exercises, and then I am starting to get into things after 12 weeks. Most of the people that I saw at our fracture clinic were elderly, and they were taking many months, even more than six months, to totally recover. So I would often refer them back to their GP for a care plan or a physio.
So I will just hand over to Andrew from Essity just to talk about the arm sling.
Andrew:
Hi. Just a couple of tips when using a sling of any nature, make sure that you have the elbow into the corner of the sling itself. Make sure you trim down all the tabs just to make sure they do not get caught. And as John explained, the rationale of when to use it, when to take it off. If any acute thing that you are sending off, please put them in something like this. Sorry, I am allied health, so this is something that is really important for us. You can see here, in a lot of the slings, they will have a little thumb hold, again, that is just to help with the stability of it. If you do have a sling which can go around the waist, that makes it even better for that little bit more stability in terms of any type of humeral fracture that you might see. John.
John:
Thanks, Andrew. I met Andrew last year. We put a fracture management and urgent care day on for ForHealth down in Sydney, and Andrew and his team came in and taught the group of GPs and nurses how to put on a lot of the common plasters and joint immobilisers for upper and lower limbs. Most recently, we did the same thing in Melbourne. Andrew and his team came down there and you know, with his national role with Essity, which are a provider of these types of products, he has been absolutely fantastic to do that. And for large groups around the country, you know, very happy to bring his team down for you to do that, as well. So, thanks Andrew.
So a few complications to watch out for. So, avascular necrosis, especially with displaced fractures that we will refer. Nerve injury, and axillary nerve injury is the most common, up to 60%, and I would normally refer if there was an axillary nerve injury not settling within three months. Mal-union, non-union, always a risk for fractures. Rotator cuff and longhead of biceps injuries. So, that is why I will always examine the joint above and the joint below. Adhesive capsulitis, we certainly do not want to miss that, and that is why we do the exercises, and posttraumatic arthritis as well.
So, one of the things that I have been doing when presenting these fracture talks, is to look at the difference between New Zealand and Australia, because what is happening at the moment with the sort of 58 federal urgent care centres and the 25 each in New South Wales and also Victoria, and all of a sudden there is a big interest in this, and I am hoping that some of the item numbers will catch up to the ones in New Zealand, because then, you know, certainly doctors can provide more of this care in the community.
So, the first one we are looking at is the proximal humeral fractures. The second we are looking at is the radial head and neck fractures. So, the radial head fractures especially, I remember seeing a lot of these in urgent care, 20 to 30% of elbow fractures, and they are mostly between the ages of 30 and 60. A little bit of anatomy. The most important part is the fat pad, and you can see the fat pad up here. And you can also see the synovial cavity, which often gets filled up with blood with the radial head fractures, and the fat pad gets displaced. And we have got some x-rays that will show that.
The most common mechanism of injury is the fall on the outstretched hand. And one of the things that I will always look for, is the localised tenderness and swelling. And sometimes with this, you have actually got to put your thumb on the person’s radius and get them supinate and pronate, to see if they have got a radial head fracture. I will just stand up again to show you this. But I will often put my thumb on the patient’s basically radial head, and I will supinate and pronate, and that will give me a clue that there might be a radial head fracture going on there. Also, oftentimes when you examine the patient in flexion and extension, they cannot extend properly, they might only be able to extend to 45 degrees. If I am worried about a radial head fracture or a radial neck fracture because of tenderness from thumb pressure, I will always ask for radial head views, because they will allow me to see this better.
There are a few fractures that I will send to an orthopaedic surgeon. I use the Mason criteria. So you can see up here, Mason type 1. It is non-displaced or minimally displaced and we talk about the minimally displaced here as less than 2 mm and no mechanical block to rotation. So you can supinate and pronate. So, these are the ones that we would be happy to manage in primary care. The type 2s, there is displacement there. Displaced more than 2 mm or angulated, and sometimes there is a block to supination and pronation. Type 2 is comminuted and displaced. Type 4 there is associated dislocation. So we will not be managing the type 2 to 4 injuries.
Here is a few examples of Mason injuries that we would refer. Here is a CT scan of one, and this is a fracture of the radial head with intra-articular extension, and there is more than 2 mm displacement there, so that is why we would refer this fracture.
Here is another fracture, Mason type 2 here, with a 5 mm distal displacement, above a 10 mm fragment, and that requires orthopaedic surgeon review.
The second fracture to refer is called the Essex-Lopresti fracture dislocation. A bit of a mouthful, and it is not a common one, but you do not want to miss it. So, these injuries are caused by severe compressive forces, from fall on an outstretched hand, and what it does, is basically you get the comminuted fracture, the radial head, but you also get a dislocation of the distal radial joint. So you can see that here with the ulnar proximally dislocated. The big worry with these is the intraosseous membrane that also gets torn as well. And up to 80% of these are missed at initial presentation and the outcomes are historically poor. So, if you examine the joint above and the joint below, it gives you clues to these types of injuries.
Another one is the terrible triad. I do not think you will miss this if you x-ray patients. And this will be very swollen. But you have got elbow dislocation, you have got radial head and neck dislocation, and you have also got a coronoid process up there. You have got a fracture there.
And the last one that does come into the general practice and urgent care, and rural general practice sometimes, is the Monteggia fracture / dislocation. And these involve basically the proximal third of the ulnar shaft, and also radial head dislocation. It is important to examine for fractures of the distal radius anyway, because in kids especially, these can be missed. Usually, you get kids aged four to ten with these types of fractures, you do not see them too often in adults.
Here is a fracture that I would be managing in general practice. You can see there is a non- or minimally displaced fracture of the radial head. You can see the positive fats pad sign there from the haemarthrosis. Another interesting point about the fat pad sign is, if I see a fat pad sign that is positive in an adult, even if I cannot see a fracture, I will treat it as a radial head fracture, a clinical radial head fracture. If I see a fat pad sign in a child who has got growth plates, I will be worried about an undisplaced supracondylar fracture, and I will often treat them as such.
So, how do we treat Mason type 1 fractures? Well, we like to get things moving as quickly as we can, so what I will do is I will immobilise them for three to seven days. Depending on how painful they are, I will often use a collar and a cuff, sometimes I will use a shoulder immobiliser. You have just got to be careful about ongoing stiffness with prolonged immobilisation. So, I am going to hand back to Andrew. He is just going to talk about the collar and the cuff.
Andrew:
I think this is a very important piece of material you should have in your clinics. It comes in a roll like this. It lasts you the year. You put any upper limb in something like this. You can do all sorts of things to it to make different types of sling. So the picture you see on the top there is just your simple broad arm sling. Something similar to what we showed before, and then you have got a much simplified version there, where you cut off a piece, you wrap it, use the Y tabs that are in the box, like that, you can turn it inside out, make yourself a little arm hole, so you have got two holes like that, and then you have got a simple sling. So, very easy to use, your practice nurses can help apply this, and it is a must have in a clinic when considering you know, intervention and immobilisation of fractures seen earlier.
John:
Thanks, Andrew. So a few complications that we watch for. Firstly and secondary, displacements of fractures, so this is less than 5% of patients treated non-operatively. Hopefully this will not be the Mason type 1, but goes back to the introduction. My general rule of thumb is, I see patients and I x-ray them on day zero, when they come back at day 7 to 10, and depending on the fracture, I will often x-ray them at the end of the fracture management episode to confirm that there has been no slippage or displacement and that the fracture is, you know, clinically and radiologically healing, or clinically healed but radiologically healing.
Elbow stiffness and loss of forearm rotation is common, in fact it is something I warn patients of, because often at three weeks, or three months should I say, when they try and fully extend, there might be about 10% of extension that they will not be able to get. Myositis is again one that I always warn people about, because if they cannot entirely straighten their elbow, you do not want their mate or their family pulling on that, active movement is fine, which is movement by yourself, but having someone pulling at it, can cause myositis ossificans, and you can get a whole lot of calcification that needs surgical removal. So, we discourage passive movement when we are healing the radial head fractures.
So looking at the difference between New Zealand and Australia. I would often see a patient at least three times for a radial head fracture at 120 dollars. In New Zealand, they pay a little bit more for fracture management, so you would get around two times what we get over here.
We also see radial neck fractures. They are less common, and I will often those in either a sling or collar cuff for two to three weeks to let that fracture set, and then I will start to mobilise it. So if it is tilting less than 20 degrees in adults, or less than 30 degrees in children, that is acceptable. So, firstly, we talked about proximal humeral fractures. The next common was the radial head and neck and the third one I want to talk about today is carpal fractures. The most common being the scaphoid fracture.
So, scaphoid fractures are more common in males, usually in the third decade of life. You do not see too many of them sort of especially in young kids under 11, and elderly patients, as the scaphoid is stronger than the distal radius.
So just looking at some of the anatomy here. So here is the scaphoid bone. It is obliquely orientated in the long axis. It is the largest bone in the proximal carpal row here. Most of it is covered by articular cartilage. There is three common parts, there is the waist fracture just across here, and 70 or 80% of the fractures of the scaphoid will be waist fractures. There is the distal pole. So this is the scaphoid tubercle here. That will be 20%. And then there is the proximal pole here, which I am always a bit nervous to manage, because of poor blood supply.
Just a reminder of scaphoid blood supply. So 80% of the scaphoid blood supply is retrograde. So you can see the blood supply coming out and then coming back here. So, lots of good blood supply in the distal pole here, but less in the waist, but not so much in the proximal pole. So the last thing we want, is to miss especially a proximal pole fracture, which I would not manage, and then the whole part of the bone, the proximal scaphoid bone, basically starts to disappear, and then you get the rotation of the proximal carpal row. It is a real disaster if you miss those. So, commonly caused by a fall on outstretched hands. There is a few provocative tests, clinically that I would use, and it is 80% to 100% sensitivity, but not quite as good as specificity. So, the first one is the anatomical snuffbox tenderness. So basically, I am pushing on the anatomical snuffbox here. Secondly, the scaphoid tubercle tenderness here over the proximal scaphoid. And the third, is the scaphoid axial compression test. So, basically what I would do is I would have my thumb over the scaphoid tubercle proximal scaphoid, and I would have my index finger on the dorsal aspect of the hand, and I would be pushing those. So, if I use all three tests within 24 hours, a lot higher sensitivity and specificity.
Next, I would do an x-ray, and I would ask for scaphoid views, not just wrist views, wrist and scaphoid. The next investigation if that x-ray is normal depends on where I am at, which part of the world. So, of all the patients with clinically suspected scaphoid fractures, less than 20% will actually have scaphoid fractures. An x-ray also misses 15 to 20%. So it is worthwhile knowing that. If I am still suspicious of a scaphoid fracture, I will manage the patient in a scaphoid cast. I will do that for 10 to 14 days, and then I will get them back and re x-ray them again. If the x-ray is normal, then I will put them in a splint for four weeks and then if they are not settling, I will normally order a CT or MRI. You can order a bone scan, but that is a little harder to get.
What is interesting, when I look at the Royal College of Radiologists, the MRI is the second line, and bone scan and CT are alternatives. In the US, CT is third line, but this presumptive casting where you put the patient in a scaphoid cast and get them back in 10 to 14 days and re x-ray, that is accepted as second line. The important thing to note here is the sensitivity and specificity, the chance of the imaging showing a fracture when there is a fracture, is not 100%. So if a person is really sore there, it is good to put them in a cast, immobilise them, and repeat. Having said that, there are certain professions where it is much more important than not to put people in casts at all, you know, especially if someone is a bus driver or you know, a professional where they could not function if they had a cast, and you are not 100% sure, then I would go get a CT, but it is not 100% even early on.
So the fractures that I will refer. So, if I see a non-displaced waist fracture and I have got an athlete, I will send them for an orthopaedic opinion, because they will get back to sport or work quicker. If there is displacement more than 1 mm, I will send those. I will send the proximal pole fracture ones, because the blood supply is not perfect and the rate of non-union is quite high. Comminuted fractures, I will also send. Here is an example of what I have talked about before, about something looking munted. So, this is called a trans-scaphoid peri-lunate dislocation. And a number of orthopaedic surgeons that I talked to, when I talk about GPs managing fractures or nurse practitioners managing fractures, they will almost always bring up the example of the trans-scaphoid peri-lunate dislocation. And you can see there, the scaphoid is fractured here. But also on the lateral, you see the lunate in place there, but the capitate is dislocated. These are disastrous if they are missed. So if it looks weird, it is always good to get an opinion or if you have got access to a CT, to do that.
Here is an example of non-union. So, basically this fracture has not healed. A percentage of fractures, you will get that, but you would certainly be referring that to an orthopaedic surgeon. Here is a hump back deformity, which is basically the intrascaphoid angle here greater than 35 degrees. You would often notice something clinically, there would be a bump, there might be an abnormality on x-ray that you would need to follow up.
So the ones that I manage in the rooms are the waist fractures, the distal third and the displacement less than 1 mm. I would manage those in general practice. And if the scaphoid was tender, I would put a presumptive cast on for 10 to 14 days. I would re x-ray in 10 to 14 days. If the x-ray was normal, I would do a wrist splint for another four weeks and then do CT, MRI of bone scan. Cast time depends on what type of fracture you are managing. So, the distal third, six to eight weeks, the middle third eight to 12 weeks and I would not manage a proximal third fracture but they are often managed a lot longer in cast.
So the conservative ones that I would manage. Here is an undisplaced fracture of the scaphoid waist, and there is obviously some advanced wear and tear there. Because that was undisplaced, I would manage that in general practice.
Here is an example of a fracture of the distal third of the scaphoid here. The blood supply is good, because the blood supply comes around in a retrograde manner. So, because this is displaced less than 1 mm, I would be very happy to manage this in general practice.
So I will hand back to Andrew to show us the scaphoid cast.
Andrew:
So you will definitely see this one. We call it a thumb spiker. As John said, because of the poor blood supply, in terms of a back slab, where we are normally looking for 50% coverage to allow for the swelling, because of the poor blood supply, we can you know, go a little bit more circumferential around for that stability as well. So, in terms of positioning for a scaphoid, you can see there you know, there was a hold beer can, or holding in a position like this, what we tend to say is, just make sure that the thumb is in alignment with the radius. So you will put yourself in wrist extension of about 15 degrees, and that is the position of safe immobilisation. In this slide here, we are looking at the Plaster of Paris, the Gypsona, you are looking for about 8 to 10 layers of that to put as your back slab, and you mould it around the thumb, and remember, it takes quite a while to set, you know, anywhere from 24 to 48 hours. Hence, we put them in a sling to make sure that the cast does not break on discharge. But yes, a definite back slab that you will encounter. It is a top three in ED. So, it is something we definitely see.
John:
So Andrew, I noticed that this is a back slab, not a full cast. When did that change?
Andrew:
Look, this is just for our primary immobilisation. It would then go as you said, or on the doctor’s suggestion, that we then put them into a secondary immobilisation, where we will put that colourful tape on in terms of putting on a more permanent cast that would last for the six to eight weeks, might help waterproof underneath so that they can shower, but that would be secondary to our confirmation of the diagnosis.
John:
Thank you. So complications of scaphoid fractures are non-union, especially if they are missed. The proximal pole fractures, always worry about those. Vertical and oblique fracture patterns. So I would not manage those. The ones displaced more than 1 mm, the other carpal fractures associated with that. So non-union, mal-union, wear and tear, the avascular necrosis especially the proximal pole, and what we talked about before, being the scaphoid non-union advanced collapse, where a part of the scaphoid you know, basically disappears and the proximal row basically turns on itself.
So, comparing New Zealand to Australia, for Australia it is nearly 220 dollars for the whole MBS management of the fracture episode. In New Zealand, you are paying per visit to the doctor for your fracture management, and it is 407 dollars that you claim for that.
So, there are a few other carpal fractures that I just want to talk about. So, here is the dorsal rim shear fracture of the hamate. So, you can just see the hamate here, there is a little fracture there. Unusually, if this was undisplaced, and not involving the base of the fourth and fifth metacarpal, I would manage this in a wrist splint symptomatically. But if there is displacement there, or involving the bases of the fourth or fifth metacarpal, I would ask an orthopaedic surgeon to help me with that.
Hook of the hamate fractures, you will not see these very often, but it is good to know about them. So, if someone is very tender over the hamate, and their x-ray is normal, I might put them in a wrist splint. But sometimes, if they are not settling after two or three weeks, I might have to do a CT, because the hook can be fractured. And that can happen sometimes when you catch hard objects like cricket balls and often, they will settle by themselves, but if they do not, the hook sometimes has to be surgically removed.
Another one that we see from time to time is avulsion flake fractures, and you will often see it on the dorsal side of the lateral x-ray here. So you will get these severe hand sprains and you will get ligamentous tears. Sometimes you will only see them in the lateral, sometimes the oblique. It is usually triquetrum, but it is often hard to tell, but we put them in wrist splints and get them going as quickly as we can.
A few things that it is important not to miss. It would be good to talk a little bit about carpal instability and also the way the bones are lined up in the AP. So, you have got the proximal carpal row here with the scaphoid, basically the lunate and the triquetrum, and then you have got the longitudinal chain, basically with the lunate and the capitate. So, basically, what happens is the scaphoid tends to flex, so the scaphoid being number one, and the triquetrum tends to extend.
So I am just going to talk about Mayfield progression, because when high energy falls on hyperextended wrists, you can have various injuries that follow this Mayfield progression. So, early phase of the Mayfield progression is stage 1, and you have got scapholunate, so scapholunate here, dislocation, you can see that in the AP here, there is a gap. Like a gap in a tooth. So when I am examining the scaphoid I will feel for tenderness in the scaphoid and the lunate, because there is a ligament there you do not want to miss those injuries. Stage 2 and stage 3 involves the capitolunate ligament here, and this is the lunotriquetral ligament, and that is when you get those trans-scaphoid perilunate dislocations. Same x-rays as I showed before. This is the scaphoid fracture here, and this is the lunate popped out. And remembering, if it looks munted, if it looks abnormal, call ortho, sometimes get a CT if you are not sure.
In this stage 4, so we have gone from all those ones we talked about before, scapholunate dislocation, capitolunate ligament disruption, lunate triquetral disruption, and this is the radiolunate ligament disruption here, and you can see that the carpal bone here is basically just popped out, the lunate has just popped out here. So you certainly do not want to miss that. So another x-ray that looks munted.
So now we want to move onto the lower limb. We want to talk about patella fractures and tarsal fractures. We do get sent quite a few patella fractures for our fracture clinic, and they are certainly manageable in general practice. So more females than males, mainly 20 to 50-year-olds. The patella is the largest sesamoid bone, it is a fulcrum and you can see up here, it is bipartite in 2 to 3% at the upper outer quadrant and you have got smooth borders on the patella.
A few common mechanisms of injury. First of all, falls or dashboard injuries, where the knee smacks against something. Indirect eccentric contraction in athletes and the patella sleeve fractures in 8 to 16-year-olds. It is important to know about these. You will not see them too often, but you do not want to miss those. When you are examining people, examining for haemarthrosis is important, and also see if they can straight leg raise, because you want to see if that extensor mechanism is intact. So the ones that I will refer for an opinion, are if there is extensor mechanism failure, that is when I cannot elicit a straight leg raise. Open fractures, articular steps more than 2 mm, or displaceable and 3 mm. Sometimes you will get loose bodies and osteochondral fragments and of course, the childhood patella sleeve fracture, where you might feel a bump, you might get a little avulsion fracture at the base on the patella. But suspicion is important, and they will not be able to necessarily hyperextend their knee.
So we will often manage these patella fractures in a range of motion brace, and I was lucky enough with Sunshine Coast Hospital Health Service to be given a supply of these so we could manage these fractures. 95% excellent results when you are using them for the proper indications. So if there was a vertebral fracture, a vertebral fracture that was undisplaced, for the first three weeks, I would put it in a splint or range of motion brace, locked in extension, so they could not bend it. I would give them crutches and I would give them weight-bearing as tolerated. After the three weeks, I would slowly increase the angulation of the brace to 90 degrees, and then after the six weeks, that is your physio. The only difference for horizontal fractures is that you would x-ray them at three weeks just to make sure there was no late separation. So I was always taught, and I do this, you are never going to get into trouble for x-raying a patient when they have got a fracture at 10 to 14 days when they come back and at the end of the fracture management episode.
So I will hand back to Andrew for discussion on the range of those.
Andrew:
Yes. So, as John was saying, that you put them in a Zimmer type splint first, there is obviously the hard struts on the lateral and medial aspect of the leg. The patella would go in the middle. This would be your primary mobilisation plan, and then you would move to the ROM with consultation with hopefully someone in your network, your allied health network, to help you through that process using the integration of the increasing of the angles as part of their treatment plan.
John:
So, here is a fracture of the patella. It is a horizontal fracture you can see here, where the patient was playing footy. There is an effusion, there is reduced range of movement, and I would be managing them. Then there are in the splint or range of motion brace for the first three weeks locked in extension. I would x-ray after three weeks, and then I would increase slowly over the next three weeks the angulation of the range of motion brace to 90 degrees, and then send them to physio after that. Complications, stiffness, osteoarthritis, basically wasting away, avascular necrosis, non-union, mal-union. And just looking at the different remunerations between New Zealand and Australia, it looks like you get more in Australia than New Zealand. In New Zealand, they pay for the splint as well. We were lucky enough to have the Sunshine Coast Hospital and Health Service help us with these, because it does make a huge difference if you can manage a patient in their community, close to their home with the same treatment as they get in the hospital.
So the last type of fractures we are going to talk about is tarsal fractures. And thanks so much for sticking with us on a cold winter’s night. Even on the Sunshine Coast here tonight, it is cold. So, with talus fractures, the neck fractures are 50% as the neck is the weakest part of the talus. There is also the body fractures, which are 20%, but there is potential for wear and tear if they extend onto the articular surface. So a little bit of anatomy here. So, the talus has the head and that basically attaches to the navicular and cuboid bone. You have the talar dome here, which attaches to the tibia and fibula, and then you have got the subtalar joint and that attaches to the calcaneus. 57% of the talus is covered by articular surface, so there is not as much surface area for blood supplies. So, we are talking about talar neck fractures now. So, this is basically a high energy pedal impact, so car accidents, light aircraft crashes and falls from height in crouching positions. People are living a lot through these types of injuries more, so they are seen a little bit more.
When I am examining for talar, well, basically any talar fracture, I am always going to examine the joint above and the joint below, because especially in these injuries, you know, 48 to 49% will be associated with other injuries. If I am suspicious, I will do a CT or a x-ray, because quite a few of these fractures, you will not see them on x-ray. I will always assess the neurovascular status. So, we use the Hawkins criteria for management of these fractures. The type 1 talar neck fractures, that is nondisplaced, but there is still a zero to 13% risk of avascular necrosis. So with these, even if I was in the country managing these, I would involve an orthopaedic surgeon. As you go up the criteria, you get more and more risk of basically avascular necrosis. So if I was managing a Hawkins type 1 fracture which is nondisplaced, I would put the person in a cast for 8 to 12 weeks, non-weight bearing initially, I would do a CT to exclude other injuries, just to confirm that the fracture was nondisplaced and there was no stop off, and that would cover a lot of the other injuries that I would be worried about missing.
So, I will just hand over to Andrew there just to talk about putting on a lower leg cast.
Andrew:
Basically here we have got a picture of what you would need to apply a back slab for a lower leg. John, we will go to the next slide. If you are a one man show, which some of you guys are in rural, this is the best position to have them in if you can get them onto their stomach. If you possibly can have an assistant, it is a two man job. The back slab goes directly on the posterior part of the leg. If it is very unstable you can do a U slab, collect the medial, lateral, malleolus as well. Preferably, if there is some stability with a fracture post x-ray, I would tend to put them into a boot. As a lot of people are doing that now, even through ED for suspected low leg fracture or stabilised fracture of the lower leg.
John:
Thanks. So, a couple of other talar fractures. So, there is talar body fractures which are vertical splits. And if they did not involve the subtalar joint, you would treat them as type 1 talar neck fractures. Again, I would always involve an orthopaedic surgeon with any talus or calcaneus fractures. Any talar body fractures, that is in intra-articular and involves the ankle joint, definitely needs referral. Talar dome, it is important to know about these fractures. I talked about these a little bit last time in the ankle fracture talk. As a former basketball player, and you know, knowing about colleagues where talar dome fractures have been missed and that has been the end of their career, I always examine for this when I am examining for ankle fractures. Funnily enough, I just saw a basketball player today that looks like he has a talar dome fracture. But if I saw a talar dome fracture, I would put a patient in a cast, and then I would send them to an orthopaedic surgeon. Sometimes the fracture fragment will be removed arthroscopically. Sometimes, it will fragment and screws will put the fracture fragment back on. The lateral and posterior process fractures, you can manage them if they are nondisplaced, but I would always involve an orthopaedic surgeon and for the minor avulsion fractures, I would systematically treat those with a moon boot or a walking plaster.
So the complications that you always have to watch for. So, there is the avascular necrosis, especially the talar neck fractures. The varus malunion, where patients are walking abnormally on the outside of their foot, and the secondary posttraumatic arthritis.
Another fracture that we will talk about in the next couple of minutes before we finish is the tarsal fracture. The commonest is intra-articular. A percentage are open and a percentage are the calcaneal tuberosity.
More anatomy here. The calcaneus is the largest part of the tarsal bones. You have got the talus appearing here. You have got the cuboid anteriorly and you have got the achilles tendon at the back here. Bohler’s angle is important to know about. You can see here you have got a line from the anterior process of the calcaneus, to the highest point of the posterior articular facet, and from the posterior articular facet here to the highest point of the calcaneal tuberosity. So, this is normally 25 to 40 degrees, but in intra-articular fractures, this can be less, it is a clue to a calcaneus fracture.
Another important anatomical landmark is when we are looking at the posterior part of the calcaneus. Basically here you have got the superior facet there from the retrocalcaneal bursa, and the middle facet is where the achilles tendon attaches. Looking at anatomy here, just from that last view of the posterior part of the talus, it is the Sanders classification. If the fracture is undisplaced, it is type 1. If there is two fragments across here, it is type 2. If there is three fragments, it is type 3. And if it is comminuted with more than three lines, it is type 4.
So common mechanisms of injury is basically falling from a height, having underground explode on you, car crashes. With the articular ones, it is the contraction of the achilles tendon with forced dorsiflexion, and we are always watching for stress fractures and anterior process fractures.
When I am examining the foot, I am looking for swelling and widening of the heel. And there is a few fractures that I will refer, but if you can see here at the top of this x-ray, there is a fracture of the superior part of the calcaneus. This is called a tongue fracture, and you can have a lot of pressure from the tongue fracture on the skin. Open fractures I will refer, neurovascular compromise and compartment syndromes, especially when there is a lot of pain. The extra-articular fractures if they are more than a centimetre, or displaced more than 2 mm, and also the anterior process fractures and displaced fractures of the sustentaculum. Sanders type 2 to 4, I would definitely refer those.
So all calcaneal fractures that are a paediatric should be discussed with orthopaedics. Even the adult ones, the ones that have the fracture fragment less than 1 cm in size or displaced less than 2 mm with an intact achilles tendon, I would manage those in a cast or moon boot, for 10 to 12 weeks, but I would discuss them with an orthopaedic surgeon. Also the Sanders type 2 anterior process fractures, tuberosity fractures displaced less than 1 cm and the Bohler’s angle fractures.
The complications that we are looking for is the wound complications, especially the tongue type fractures in smokers, and the arthritis, compartment syndrome, malunion. And this is comparing New Zealand and Australia. If you are to manage one of these as a GP, it is three times as much as what you would get in Australia.
So, a few references here that I have been using just for the talk there. And I will hand it back to Serena.
Serena:
Thank you very much, John, that was a very informative webinar. A reminder to everyone to please complete the evaluation that will pop up in a moment when the webinar session closes. It really takes no more than a minute to complete. Certificates of attendance will become available on your CPD statements within the next few days, but for any non-RACGP members who would like a certificate of attendance, please email us at Rural@RACGP.org.au. Do not forget to tune in to our other free monthly webinars held on the first Thursday of every month. And on that note, I will now end the webinar, and I wish you all an enjoyable evening. Thank you, and good night.