Common Fractures

COMMON FRACTURES: RECOGNITION AND MANAGEMENT
AAFP Board Review 2006

Gaetano P. Monteleone, J r., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@rcbhsc.wvu.edu
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I. Fracture Terminology
A. Open vs closed
B. Simple vs comminuted
C. Intra-articular vs extra-articular
D. Fracture Patterns
Transverse
Oblique
Spiral
Impacted
Longitudinal

E. Anatomic Fracture Description
Displacement
Angulation
Rotation
Separation

F. Special Pediatric Fracture Patterns
Greenstick
Torus
Plastic Deformation
Physeal Injuries

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II. Upper Extremity

A. Clavicle Fractures
1. Mechanism =fall on outstretched hand or directly on lateral aspect of shoulder.
2. Classification:
Proximal third

Middle third (most
common)
Distal third

3. PE- pain to palpation of clavicle +deformity
and crepitus.
4. Dx- H&P, Xrays- usually a superior
displacement of the proximal fragment by the
sternocleidomastoid m.
5. Rx- Most proximal and middle fx respond well
to figure-of-eight bracing or clavicular strapping.
Distal fx with significant displacement may
require REFERRAL to orthopedics. However,
most distal fx can be managed appropriately by family physicians. Figure-of-eight or sling for 3-
4 weeks in children, 4-8 weeks for adults. When clinical healing start ROM exercises to pain
tolerance. Expect exuberant callus formation. May cause compression of neurologic structures
underneath (brachial plexus) at 2-3 months. Rx for this is resection of callus. REFER any
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severely displaced or comminuted fx.

B. Proximal Humerus fractures- good blood supply to the proximal humerus allows for
better healing of fractures in this region. Beware fracture-dislocation.
1. Hx-most occur in elderly from fall on outstretched hand. Patients may have a h/o osteoporosis
or falls risk. Generalized pain to the shoulder region with lack of interest in moving upper
arm/shoulder may be the only history.
2. PE- fairly nonspecific. Inability to move upper extremity, +ecchymosis to shoulder region.
3. Rx- fractures with no or minimal displacement are treated with nonoperative methods. The
mainstay in this case is immobilization from 1-3 weeks, and pain control/comfort measures.
Early gradual mobilization (3 weeks) improves mobility and reduces risk of adhesive capsulitis.
REFERRAL for surgical treatment is indicated if comminuted fractures, younger patients or
fracture-dislocation.

C. Supracondylar Fractures of the Elbow:
Supracondylar fractures are one of the most common types of fracture seen in children,
especially 5-8 years of age. They can be particularly concerning to the treating physician because
of their potential for neurovascular compromise and cosmetic deformity. Roughly 5% will have
concomitant distal radius fractures.
Gartland Classification-
Type I: no displacement
Type II: minimal displacement (intact posterior cortex)
Type III: moderate displacement

1. Hx- mechanism of injury =fall on outstretched hand with elbow in hyperextension (95%).
2. PE- child will not move elbow. ++swelling, +ecchymosis. Also examine distal radius to r/o
pain/fracture.
3. Dx- interpretation of the radiographs can be difficult due to subtle fracture lines and
variability in the appearance of secondary centers of ossification. Consider obtaining xrays of the
contralateral, uninjured elbow (comparison views). When a fracture line is not visible in an
obviously injured elbow, analysis of fat pad signs and the anterior humeral line can be used to
determine the likelihood of an occult fracture.

Special Considerations in Reviewing Pediatric Elbow Xrays
Fat Pads: The posterior fat pad sits in the olecranon fossa and is not visible on a true
lateral projection of a normal elbow. When a radiolucent (dark) stripe is visible in this
area, a posterior fat pad sign is present. A visible posterior fat pad is associated with
fracture of the elbow in 80 to 100% of cases. The presence of a posterior fat pad is
always pathologic. The anterior fat pad sits in the shallower coronoid fossa and therefore
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is sometimes visible on lateral elbow films
as a thin radiolucent (dark) stripe
overlying the distal anterior humerus.
With traumatic injury, joint effusion lifts
the fat pad from its normal position
creating a "sail" shape.

Anterior Humeral Line-The anterior
humeral line (AHL) is visualized on a
lateral radiograph by drawing a line
along the anterior cortex of the humerus
through the capitellum. Another line can
be drawn on the lateral xray along the
radius, also intersecting with the
capitellum. The AHL normally intersects
the capitellum in its posterior two-thirds.
Hyperextension of the elbow that causes
a supracondylar fracture typically causes posterior angulation of the distal portion of the
humerus resulting in an AHL that intersects the capitellum in its middle one-third.

4. Rx- elbow fractures in pediatric population may require orthopedic consultation. Type I
(nondisplaced fractures) are usually treated
nonoperatively with posterior elbow splint at 90
o
.
Type II and II supracondylar fractures are usually
treated surgically.
Complications(especially with displaced fractures)-
neurovascular compromise (including Volkmanns
contracture), permanent angulation deformities.

D. Monteggia Fracture-Dislocation
1. Definition- fracture of the shaft of the ulna (especially the proximal third) associated with
radial head dislocation. Hx- Pain and diminished motion at the elbow.
2. PE- significant tenderness and swelling throughout the elbow and forearm; Check neurologic
and vascular function distally.
3. Dx- xrays will show this fracture-dislocation well, especially the lateral view. Consider
comparison views of unaffected side if necessary. Consider wrist films in addition to elbow
films.
4. Rx- elbow fractures in pediatric population should have orthopedic consultation. In children,
most can be treated with closed reduction. Of primary importance is the reduction of the radial
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head dislocation. When the capsule or annular ligament prevent the radial head from relocating,
surgical intervention is required. If anatomic reduction of radial head and ulna are achieved, the
elbow is immobilized in ~100
o
of flexion and full supination. Also, most authors agree that
Monteggia injuries in adults need to be surgically treated.
Complications include neurovascular compromise, angular deformities.

E. Distal Radius
1. Colles Fracture (distal radius with dorsal angulation): Fall on outstretched hand in
hyperextension. PE with obvious "silver fork" deformity, edema and ecchymosis. Beware
coexistent ulnar fracture, distal radioulnar joint (DRUJ ) subluxation/dislocation, median nerve
palsy and referred injury. Xray consistent with above. Assess follow-up xrays at 2-4 weeks for
delayed displacement, angulation, shortening of radius and callous formation. Treatment as
below:
Undisplaced, minimal angulation: short arm cast (with wrist in slight flexion and ulnar
deviation) for 4-6 weeks.
Mild displacement/angulation >5 mm loss of radial height, and >10
o
dorsal tilt of distal
radius (normal wrist has ~10-15
o
of volar tilt): long arm cast while maintaining traction.
Manipulation via distraction and volarly directed force. Obtain post-manipulation xrays.
Consider weekly xrays for 3-4 weeks if manipulation required. If difficult to maintain
anatomic reduction, REFER to surgeon. Some authors advocate referral of any fx
requiring manipulation.
Moderate-to-severe displacement/angulation or associated injuries (DRUJ dislocation,
median nerve palsy, etc.), REFER to surgeon.
2. Smith's Fracture (distal radius with volar angulation) AKA reverse Colles: Mech =fall on
back of flexed hand. Much less common than Colles fx. Xrays demonstrate volar angulation. If
fx line is transverse (type I), treatment with short arm cast for 4-6 weeks.
3. Torus and Greenstick Fractures- also check for concomitant ulnar injuries. Treatment the
same as above. REFER large displacements and angulation (>30-40). Expect quicker healing
in this pediatric age group than with fractures above.
4. Radial Styloid Fracture- (AKA Chauffeur's fracture: kick-back on hand crank to start engine
struck forearm)-minimal displacement, angulation =cast immobilization. REFER for
displacement, angulation.
Note- consider short-arm thumb spica cast in the above situations if significant pain with thumb
movements, and long-arm thumb spica cast if significant pain with supination/pronation
movements.

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F. Scaphoid Fracture
1. Mech =fall on outstretched hand with wrist in
hyperextension.
2. Classification - Proximal pole (30%), waist
(most common, 50-60%), distal pole and tubercle
(the latter two combined account for 10% of all
scaphoid fx). Vasculature often enters from the
distal pole, running proximally. Fractures,
therefore, of the proximal pole are at risk (30%) for
avascular necrosis. This phenomenon is immediate
in onset, but may take 1-2 months to become
visible on xray.
3. PE =pain in anatomic snuffbox and/or palmarly.
Decreased ROM.
4. Radiology - AP, lateral; oblique and scaphoid (AP in ulnar deviation) views can be helpful. If
negative, repeat at 2-4 weeks or obtain bone scan. Diagnosis requires high clinical suspicion. If
tenderness and negative radiography, treat as if fx.
5. Treatment- if undisplaced fx, rx with thumb spica cast (wrist in slight radial deviation).

Location of Fracture

Duration of Casting

Distal Pole

6-8 weeks

Waist

8-12 weeks

Proximal Pole

12-24 weeks

Some authors utilize a long arm thumb spica cast initially (for about 2-6 weeks), then switch to a
short arm thumb spica for the until fx line healed radiographically. If continued pain or evidence
of avascular necrosis/nonunion at 12 weeks, referral to surgeon is appropriate. If displaced fx
referral to surgeon for screw placement.

G. Thumb fractures:
1. Bennett's fx- intra-articular fx of base (proximal end) 1st metacarpal. The abductor pollicis
longus tendon pulls the shaft proximally as the deep ulnar ligament holds the small base
fragment stable. Surgery (percutaneous pinning vs screw fixation) is best to maintain the
anatomic reduction. Do not confuse this fx with an extra-articular fx which responds well to
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nonsurgical treatment.
2. Rolando's fx- comminuted, intra-articular fx base of 1st metacarpal. Large fragments surgery
may help. Small fragments require casting with early mobilization @5-10 days. It is surprising
how well these fx will mold together resulting in a joint that allows adequate ROM.

H. Hand Fractures:
1. Boxer's fx- fx of the neck of the 5th metacarpal with volar angulation of the head of the
metatarsal. If undisplaced, angulation <40
o
, then ulnar gutter splint for 4 weeks usually
suffices (4th and 5th metacarpals). Refer if large angulation, displacement, rotational deformity.
With 2nd or 3rd metacarpal neck fractures, referral for angulation of > 5-10
o
is standard of care.
2. Metacarpal shaft fx- 3rd, 4th and 5th common. Similar treatment options as above.
Rotational deformity assessed by flexion of all fingers. With this maneuver, all fingers should
point to the scaphoid. Note: metacarpal fx are a bit more unstable due to muscular pull of the
lumbricals and interossei. Therefore, closer F/U with repeat xrays may be necessary (looking for
delayed displacement and shortening).

3. Distal Interphalangeal Joint (DIP) Injuries
a. Mallet Finger deformity- Occurs with a disruption of the extensor tendon that
normally inserts into the proximal portion of distal
phalanx. Mechanism = sudden forceful flexion of
the finger.
i. PE- lack of full extension at DIP. Pain on
palpation of dorsum of the DIP.
ii. Xrays- Usually normal, but may
demonstrate avulsion fx.
iii. Treatment- Splint X 6-8 weeks in full
extension. The DIP must remain in extension
throughout this initial splinting period or risk
re-injury. Common splinting materials are
alumifoam splints and Stack splints. If
asymptomatic after 6-8 weeks, then splint with
sports/gym/work for another 2-6 weeks. If
continued extension lag, consider REFERRAL
to discuss continued observation vs surgery.

b. Jersey finger- Avulsion of the flexor digitorum profundus (FDP). Occurs with
hyperextension of the DIP, such as a linebacker grasping for a running back's jersey.
i. PE- lack of active flexion at the DIP. Pain on palpation of volar aspect of finger.
Point of maximal tenderness may indicate site of tendon retraction.
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ii. Xrays-normal, or may show avulsion fracture.
iii. Treatment- Data demonstrates that early surgery (within one week) to reattach
tendon achieves the best results.

c. Distal phalanx fractures- Tuft and transverse fractures included in this group. Tuft
fractures are crush (comminuted) fractures of the distal phalanx that are very stable and
easily managed by family physicians.
i. PE- Pain at tip of finger. +subungual hematoma.
ii. Xrays- useful to help determine if possible open fracture. Look on lateral xray
to determine if any fragment is near the nail (use hotlight if necessary). If
fragment ? near nail bed, do not attempt decompression of subungual hematoma.
iii. Treatment- supportive, splint with basket or alumifoam splint only to the tip of
the finger. Allow mobility of PIP/DIP joints. Aspirate subungual hematoma if not
open fracture. Using larger gauge needle (18-20g) use screwing motion with some
downward pressure over the hematoma. Sometimes making two holes will allow
flow of blood more freely.

III. Lower Extremity
A. Fibular fractures- note, especially with eversion injuries.
Fibular shaft fx- often secondary to direct trauma to lateral calf (ie: helmet to calf during
a tackle. Treated with aircast stirrup brace vs. cast immobilization depending upon
severity of injury. Return to sport by 4-8 weeks. Consider Maisonneuve's fx as below.
Distal fibular fx: many classification systems. The Weber classification is as follows.
Weber A =below the mortise, B =at the mortise (joint line), C =above the joint line.
Weber C fx are usually associated with syndesmotic injuries. Current data do not
demonstrate improved outcome with surgery of isolated lateral malleolus fractures
without significant displacement. A number of studies demonstrate good results from
nonsurgical treatment of these fractures with up to 3 mm of displacement. In patients
with fractures with greater than 3 mm of displacement or angulation, consider orthopedic
referral.
Fibular avulsion fractures: occur with typical ankle sprain, but the anterior talofibular
ligament pulls with it a tiny fragment of the distal fibula. This fragment is much smaller
than the size of bone fragment associated with a Weber A fracture noted above. This
injury is treated exactly like an ankle sprain with rest, ice, aircast, elevation and pain
control.

B. Fractures at the Base of 5th Metatarsal-
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Acute, traumatic = Jone's fx. J one's
fracture is a transverse fx ~1.5 cm distal to
the tubercle. It extends into the 4,5-
intermetatarsal articulation. High rate of
delayed and non-union. Treatment =short
leg non-weightbearing cast immobilization.
May take 6-8 weeks to heal. If continued
pain at 12 weeks, refer for screw fixation.
For athletes, consider screw fixation
immediately, return to play with incision
healing.
Avulsion fx of the 5th metatarsal- fx
caused by contraction of the peroneus
brevis tendon. This fx does not involve the same risk for delayed/nonunion as with the
J one's fx. This fx has an excellent prognosis for healing. Rx as for ankle sprain. May
need post-op shoe (hard-soled shoe for sx support).

C. Hallux (Great Toe) Fractures
Hx- Mechanism of injury usually axial force (kick or stub big toe on furniture, walls, doors, etc.)
Less commonly, crush force (drop something on toe) or lateralized force on great toe.
PE- decreased ROM, significant swelling, ecchymosis; +subungual hematoma. Note fractures of
multiple phalanges are common- so evaluation of adjacent digits is appropriate.
Rx- usually requires hard-soled shoe to reduce the amount of flexion and extension that occurs
with walking. Use this splint as symptoms dictate. With some fractures buddy-taping will
suffice. REFERRAL is recommended for patients with first-toe fracture-dislocations, displaced intra-
articular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when
traction is released following reduction). Referral also is recommended for children with first-toe
fractures involving the physis. These injuries may require internal fixation.

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Common Fractures

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Common Fractures

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COMMON FRACTURES: RECOGNITION AND MANAGEMENT

AAFP Board Review 2006

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