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COVER ARTICLE/CME Urgent Care 2(10):18, 2007 The weekend athlete with signs and symptoms of upper extremity fracture is a clinical scenario on the rise. In the first of two articles, the authors present an overview of the care of these patients, including assessment, documentation, treatment, follow-up, and possible complications. As Americans have become more physically active—with people of all ages engaging in skate-boarding, snowboarding, in-line skating and the like—the risk of injury from a fall has also increased. That means the likelihood of an upper extremity fracture is greater than ever because in a fall, the natural inclination is to break the impact with an extended arm. Approximately 6.8 million fractures are treated each year in the United States. In 1994, more than 3.9 million fractures were treated in a physician’s office, 70% by orthopedic surgeons and 21% by primary care physicians. Musculoskeletal injuries comprise 10% of primary care visits, of which 6% to 14% are fractures, and half of those involve the upper extremity. This first article in a two-part series will provide a basic algorithm for evaluating upper extremity fractures, as well as reviewing treatments and potential complications in care. EVALUATING THE INJURY In the initial evaluation of a suspected fracture, you’ll want to first gather information about the mechanism, duration, and location of the injury. Certain mechanisms of injury—for example, a fall onto an outstretched hand, a flexed wrist, an elbow, or a shoulder—often result in specific fractures and can be useful in the diagnosis. Duration of the injury is particularly important for a number of reasons. For one, when dealing with an open fracture, the risk of infection increases with time; for another, displaced fractures requiring reduction may be more difficult to treat if healing has begun. Determining the location of the injury or associated pain can also be helpful. For instance, pain that radiates down an extremity or results in motor or sensory loss may be a clue to a nerve injury. When making an initial objective evaluation of a suspected fracture, document the appearance, location, and neurovascular status of the injured area. If it is open, document that the area is clean, noting the size of the laceration and the extent of damage to the exposed soft tissue and underlying structures. The greater the damage to the tissue surrounding the fracture, the more vulnerable it is to infection or associated neurovascular injury. All open fractures need to be immediately discussed with an orthopedic surgeon to determine if surgery is necessary. Joint effusion soon after injury in the context of joint trauma is often suggestive of an intra-articular fracture. Palpation is necessary to localize the area of greatest tenderness for radiographic correlation. Also ensure that the joints proximal and distal to the area of injury are not involved. It is important to determine that the patient can move all noninjured joints and extremities. The neurovascular exam should include sensory and motor function, pulses, and capillary refill. After reduction or immobilization, repeat the exam to ensure that the neurovascular status is unchanged. All neurovascular deficits require further evaluation. OBTAINING THE RIGHT RADIOGRAPH The physical exam generally guides selection of the appropriate radiograph. The point of maximal tenderness will be the initial location for radiography, but care must be taken to evaluate all areas of tenderness. When an affected joint’s range of motion is reduced, that area should be x-rayed as well. Appropriate radiographic studies should be obtained of the entire bone in question with at least two views (anteroposterior [AP] and lateral) that are 90o apart, to minimize the chance of missing a fracture in one plane. This general rule holds true for long bones. Three views (AP, lateral, and oblique) are necessary for joint injuries; examples include scaphoid and metacarpal injuries. It’s important to be able to describe precisely the fracture seen on radiographs, including location, type of fracture, and displacement, especially when discussing the case with colleagues who will be assuming care or offering advice. There are several questions you should be prepared to answer: Where is the fracture? Which bone(s) is involved? That is, left or right fingers (thumb, index, middle, ring, small), phalanx (distal, middle, proximal), metacarpals (first through fifth), carpals (scaphoid, lunate, triquetrum, pisiform, trapezoid, trapezium, capitate, hamate), radius, ulna, or humerus? Where is the bone broken? That is, proximal, middle, or distal shaft, metaphysis, epiphysis, or physis (in children). In relation to a joint, is it intra- or extra-articular? For intra-articular fractures, it is important to document disruption of the joint surface. Any incongruence is unacceptable and will need further evaluation. What type of fracture is it? Description of the fracture includes the direction of the fracture line, number of fragments, fracture angulation, and injury force. The fracture line can be described in terms of transverse, oblique, or spiral (see first image below) and the number of fragments in terms of simple, comminuted, or segmental (see second image below). The fracture angulation can be measured with a goniometer and described in relation to the apex—for example, “angulated 19o, apex volar” (see third image below). Fractures can also be described based on the applied force forming the fracture fragments—for example, impacted, avulsed (see fourth image below), compressed,
or pathologic.
Injury forces often cause a certain degree of displacement, described as translation, angulation, shortening, or rotation. Translation is the movement of the fracture from anatomical alignment in the AP or mediolateral planes. It is also useful to quantify the translation in millimeters or percentages and the direction (volar or dorsal, radial or ulnar) of the distal segment (for example, 50% or 5 mm dorsally translated). Angulation occurs in the frontal or sagittal plane, or both, and requires true AP and lateral x-rays (90o apart) to be accurately measured with a goniometer, as discussed above. Shortening may occur from compression and might require surgery to restore length. Rotation occurs as a result of deforming forces (such as trauma, gravity, or muscle pull) and is usually detected clinically. Fracture terminology is summarized in the first box below. Guidelines for evaluating fractures are presented in the second box below.
CASTING GUIDELINES The first thing to do for an upper extremity fracture is to immobilize the arm to reduce pain. Reduction of the fracture may be necessary, but this should be done only by a clinician with proper training and experience. An inappropriately reduced fracture can lead to further complications and injury. Plaster casts are heavier but they are also cheaper, easier to shape, and have a longer shelf life. The fiberglass form is lighter, more durable, and comes in a range of colors. At least two layers of padding material must be applied under the cast. Extra padding (three to four layers) is needed for bony prominences, but avoid excess padding at the fracture site to minimize movement. Also avoid manipulating the casting material too much. Do not create indentations in the cast, which may induce pressure points. Cut a window if needed for visualization—for example, over the open wound. Again, document distal neurovascular status after
immobilization. If the fracture is acute, soft tissue swells; the fracture therefore requires splinting rather than casting. Splinting allows for further swelling without compromising or constricting the affected area. Splinting also can be used to immobilize the injury temporarily until an orthopedic surgeon is able to evaluate the patient. After immobilizing the arm or shoulder, make sure the cast or splint is not too tight or loose, is the right length, and is comfortable for the patient. Check the patient’s skin for chafing. Document neurovascular status. FOLLOWING UP ON A FRACTURE Before discharge, give the patient information about protecting the healing fracture and keeping the cast clean and dry. Tell him that pain is best relieved with ice and elevation to control swelling, as well as with analgesics. You may choose to prescribe an opoid analgesic during the acute injury phase, but these drugs are usually only necessary for two to five days. Pain that requires further use of such a drug may signal a missed fracture complication. Instruct the patient to return immediately if he has any discomfort or sensory or motor deficits or if the splint or cast becomes disrupted in any way. Consider a “cast check” in three to five days. If the cast is loose after the swelling resolves, reapply it. Repeat radiographs should be taken within one week for unstable fractures to confirm alignment. Further x-rays should be taken every two to four weeks until callus formation, the radiographic sign of healing, is seen (see image below).
The cast can be removed when clinical union has occurred, meaning the area of injury is no longer tender and callus formation is apparent on radiographs. If x-rays show evidence of healing but malunion, a referral is indicated. A corrective osteotomy might be necessary for any deformity that impairs function or appearance. ON THE LOOKOUT FOR COMPLICATIONS Bone has a unique ability to heal by complete regeneration of normal bone rather than scar formation. A fracture starts to heal immediately after injury; healing continues through the stages of inflammation, repair, and remodeling. An important issue to understand is whether the bone is healing at a proper rate, and if it is not, what needs to be done. If the bone is not healing appropriately, as evidenced by a lack of callus formation, the patient should be referred to an orthopedic surgeon for possible further intervention. Several factors, including severe trauma, wound contamination, extensive soft tissue involvement, and delayed treatment can increase the risk of complications. Severe injuries can lead to pulmonary complications (fat embolism, pulmonary thromboembolus, atelectasis), infection (skin and soft tissue infection, osteomyelitis, gas gangrene, tetanus), and vascular complications (hemorrhage, ischemia). Pulmonary complications, if they occur, usually appear within 24 hours of the trauma or surgical manipulation, presenting as hypoxemia, chest pain, or tachycardia. In this case, the patient and the fracture should be stabilized immediately. Erythema, edema, disproportionate pain, and soft-tissue air on radiographs may indicate contamination by Clostridium species. This infection, which occurs through trauma or surgical intervention, can lead to gas gangrene, characterized by muscle necrosis, gas production, and potentially fatal sepsis. Tetanus infection from C. tetani enters through a break in the skin. Symptoms include headache, jaw muscle spasms, and irritability. The infection can spread, leading to more diffuse muscle spasms with painful convulsions strong enough to cause fractures. Roughly one-third of patients with tetanus die. The impact of the trauma or the fracture itself may cause hemorrhage. The patient will develop pallor, hypotension, tachycardia, anemia, and, in severe cases, shock. This warrants immediate resuscitation. DELAYED COMPLICATIONS In the urgent care setting, limb-threatening conditions, such as nerve injury and compartment syndrome, are more common than life-threatening conditions. Arterial injury needs immediate attention and can be excluded with symmetric distal pulses and normal capillary refill on examination. Nerve injury can be excluded with testing of sensation (pinprick and two-point discrimination) and motor function in all distal nerve distributions. Marked tenting of the skin, caused by protruding bone, can also lead to nerve or soft tissue entrapment, requiring the release of tension. Compartment syndrome, defined as intracompartmental pressures greater than 30 to 40 mm Hg, is diagnosed by the presence of the “five P’s”: pain out of proportion to the injury, pallor, parasthesias, paralysis, and pulselessness. None of these is very sensitive or should be considered necessary to make the diagnosis of compartment syndrome, however. A high index of suspicion regarding patients with severe pain and appropriate mechanism of injury is sufficient. Refer the patient for measurement of compartment pressures in any suspicious situation. Complex regional pain syndrome, previously known as reflex sympathetic dystrophy, is a vasomotor dysfunction of the sympathetic nervous system. Characteristic symptoms are hyperesthesia and pain out of proportion to the injury. Typically, you’ll find three distinct stages of symptoms: burning or aching, piloerection, and poikilothermia, followed by substantial edema, glossy skin, and joint limitations at approximately three months, and ending with skin atrophy and muscle/joint contractures. Treatment includes physical therapy, sympathetic nerve blocks, progressive loading of the extremity, and resistance training. Acute osteomyelitis is generally associated with open fractures or surgical reduction. The infection is usually caused by Staphylococcus aureus, although 30% of the cases are polymicrobial, including organisms such as Haemophilus influenzae, Streptococcus, Pseudomonas, and pneumococcus. Any contaminated open fractures or surgical procedures should be treated with prophylactic antibiotics to prevent infection. URGENT CONCERNS The urgent care practitioner sees a lot of broken bones and often is the critical first assessor of neurovascular status and infection risk. Moreover, simple stable fractures can often be managed conservatively, and basic splinting and casting can and should be performed in the office when materials are available, even if the injury requires surgery. Taking a thorough step-by-step approach and being alert to the red flags—the various risks and signs and symptoms of complications—will help ensure that the bone heals safely and well. Next issue...Common upper extremity fractures.
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