As enthusiastic emergency department clinicians, it is sometimes harder not to do anything than to actively manipulate fractures or refer them to our orthopaedic colleagues. Outlined below are four commonly conservatively managed fractures, some important things for us to know about these injuries and what to let our patients know.
Question 1 – Proximal Humerus
There is a break, is it through the surgical neck or the anatomical neck of humerus? Why is this important and how are you going to treat it?
Image sourced from http://commons.wikimedia.org/wiki/File:Surgical_neck_fracture_of_humerus.jpg9
This is a proximal humeral fracture. 85% of these can be conservatively managed. The mainstay of treatment is analgesia. It is important to do a thorough neurological examination as nerve compromise may be present in as many as 25% of these patients. Beware of those that may need surgical intervention, and so don’t always reassure the patient in the emergency department that no surgical intervention is necessary.
One method of classifying proximal humeral fractures is through the Neer Classification System.
This divides the proximal humerus into the head of the humerus, the shaft of the humerus, the greater trochanter and the lesser trochanter. Each of these portions forms a part. The Neer classification categorises the fracture according to the displacement of each of these parts relative to each other, and it may be used to determine management options.
There is a left sided sacral fracture identified as a step in the ring. This is an easily missed fracture on a plain radiograph, a diagnostic conundrum made worst by the observation that only 30% of plain radiographs will show up a sacral fracture. The Denis classification can be used to classify sacral fracture lines with relation to the neural foramina.
Class 1 fractures involve the sacral ala lateral the neural foramina.
Class 2 fractures involve the neural foramina.
Class 3 fractures involve the spinal canal itself.
In the context of clinical rib fracture, radiographs are only done if:
There are symptoms or signs suggesting an associated injury such as a pneumothorax or haemothorax
Multiple fractures are suspected. The number of ribs fractured can be predictive of complications and the patient may necessitate admission. A flail chest is when you break more than two ribs in more than two places and allows paradoxical movement of the chest wall.
Suspected pathological fractures
For documentation for medico-legal purposes, such as in cases of abuse (NB skeletal survey images should only be requested by a consultant paediatrician and agreed with a consultant radiologist. There are RCR guidelines around this.
To help direct adequate pain relief (although this should be done on a clinical basis, in patients who are unable to communicate pain effectively it may help guide the use of stronger analgesia than that used for soft tissue injury alone)
it is worth remembering that eat x-Rays are poor at identifying simplerib fractures, they are normally diagnosed and treated on a clinical basis
Rib fractures are conservatively managed but their complications should not be underestimated. Pulmonary contusions may be present in 17% of rib fractures, an associated pneumothorax in 14-35% and an associated haemopneumothorax in 20-25%. Other complications include injury to liver and spleen. The incidence of complications rises with increasing numbers of fractured ribs.
Physiologically pain from movement during breathing leads to shallow breathing, atelectasis formation, poor oxygenation and risk of infection in the lung. Therefore provision of good pain relief is imperative and the above needs to be explained to the patient.
Consider admission for elderly patients or those with significant respiratory co-morbidities such as chronic obstructive pulmonary disease. Consider admission for any patients with multiple rib fractures. PCA’s, thoracic epidurals and costal blocks may be used for analgesia and for patients with >5 broken ribs may potentially be referred to Cardiothoracics for consideration of ORIF.
Ensure that there is a history of trauma consistent with the resultant fracture? If not, consider the possibility of bone metastases and pathological fractures.
This is a base of 5th metatarsal fracture. The determination of conservative or surgical management depends on the anatomical location of the fracture line.
Zone 1 (pseudo Jones fracture): proximal tubercle only
Avulsion fracture of peroneus brevis tendon
Conservatively managed
Explain to the patient that it may take 6-8 weeks to heal fully
Protected weight-bearing as able
Zone 2 (Jones fracture):atthemetaphyseal-diaphyseal junction
Increased risk of non-union, at risk of avascularity due to blood being supplied from the proximal metacarpal end via metaphyseal arteries that branch out at this location
Manage in a non weightbearing short leg cast
Intramedullary screw fixation in athletic individuals or non-union fractures
Zone 3: diaphyseal fracture
More commonly tend to be stress fractures
Increased risk of non-union
Manage in a non-weightbearing short leg cast
At times intramedullary screw fixation in athletic individuals or non-union fractures
All of these fractures should be able to be managed through an out patient fracture clinic service
Do not confuse the apophysis at the base of the 5th metatarsal with a fracture line. Fracture lines in this area tend to be transverse as opposed to the apophyses which is longitudinal to the long axis of the metatarsal bone.
Summary
These fracture patterns are common and are normally managed conservatively. It is important not to miss similar fractures which may need operative management or associated neurovascular injuries. As with everything in Emergency Medicine if you are unsure please discuss with a senior doctor.
About the Author:
Dr Swati Gupta is an ACCS Anaesthetic trainee working in the South West of England.
Post edited and reviewed by Dr Thomas Mitchell, ED Consultant
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