Non Operative Management of common fractures · 2. Early displacement of a fracture = UNSTABLE 3....
Transcript of Non Operative Management of common fractures · 2. Early displacement of a fracture = UNSTABLE 3....
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Non Operative Management of
Common Fractures Mr Duy Thai
Orthopaedic Surgeon MBBS, FRACS (Ortho), Dip Surg Anat
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NOT ALL FRACTURES NEED TO BE
FIXED
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FRACTURE CLINIC
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FRACTURE CLINIC
EMERGENCY DEPARTMENTS
GENERAL PRACTITIONERS
SUCCESSFUL FRACTURE MANAGMENT
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FRACTURE CLINIC FRACTURE
CLINIC
EMERGENCY DEPARTMENTS
GENERAL PRACTITIONERS
SUCCESSFUL FRACTURE MANAGMENT
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PRINCIPLES
1. Always look at the X-ray – Do not rely on the report
2. Early displacement of a fracture = UNSTABLE
3. Know what is acceptable displacement
4. Plaster immobilisation of a STABLE fracture leads to secondary bone healing with fracture callous
5. Clinical union precedes radiological union by 4 – 6 weeks
6. Children remodel
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CLAVICLE FRACTURES
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CLAVICLE FRACTURES
Undisplaced
Displaced
Comminuted
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CLAVICLE FRACTURES
Non Operative Treatment • Sling for comfort initially
• Up to 2 weeks
• Start mobilisation as soon as pain bearable • Prevents shoulder stiffness
• Warn about formation of a lump at fracture site • Fracture callous
• X-ray after 6 weeks • Look for callous • Fracture line will still be present
• No loading/contact sports 3 months
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CLAVICLE FRACTURES
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CLAVICLE FRACTURES
When to refer
• Acutely
– Open fractures
– Neurovascular compromise
– > 2cm shortening
– Lateral fractures
• Delayed
– Painful non unions
– Symptomatic malunions
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CLAVICLE FRACTURES
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RADIAL HEAD FRACTURES
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RADIAL HEAD FRACTURES
Simple, minimal displaced Comminuted
NON OPERATIVE OPERATIVE
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RADIAL HEAD FRACTURES
Non Operative Treatment
• Sling for comfort only • DO NOT PLASTER
• Mobilise elbow as soon as possible
• Elbow stiffness is the biggest problem • Warn the patient that they may never regain full elbow
extension
• No further Xrays required
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RADIAL HEAD FRACTURES
When to refer • Acutely
– Open fractures – Neurological compromise
• Posterior interrosseus branch of radial nerve
– Comminuted, displaced fractures – > 2mm articular step
• Delayed – Persistent pain – Remember some degree of stiffness
is to be expected
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DISTAL RADIUS FRACTURES
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DISTAL RADIUS FRACTURES Paediatrics
Principles
• Children have a great capacity to remodel
• If the arm looks straight, then operation unlikely (regardless of what the xray looks like)
• Be wary of growth plate injuries
• Children often get greenstick fractures
• Children remodel!
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DISTAL RADIUS FRACTURES Paediatrics
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DISTAL RADIUS FRACTURES Paediatrics
Greenstick fracture United – 3mo
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DISTAL RADIUS FRACTURES Paediatrics
Non Operative Treatment
• Above elbow plaster
• Re Xray at 1 - 2 weeks • If no displacement, continue plaster for total of 6 weeks
• If displaces – implies fracture unstable – Refer
• Remove plaster at 6 weeks
• Assess for clinical union • Absence of pain at fracture site
• Pain at wrist and elbow joints normal due to stiffness
• No Xray required at 6 weeks if clinically united
• Gradually progress to unrestricted activities over 4 wks
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DISTAL RADIUS FRACTURES Paediatrics
When to refer
• Open fractures
• Neurovascular compromise
• Clinical deformity
• Growth plate fractures
• Radius AND ulnar fractures
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DISTAL RADIUS FRACTURES Paediatrics
Growth plate injury: Salter Harris 2 Distal
radius fracture
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DISTAL RADIUS FRACTURES Paediatrics
Distal radius and ulnar fracture -
unstable
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DISTAL RADIUS FRACTURES Adults
Principles
• Adults do not remodel fractures
• Normal anatomical alignment is essential
• Below elbow plasters
• Adults develop joint stiffness easily
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DISTAL RADIUS FRACTURES Adults
Normal Anatomical alignment
Radial inclination 15˚ - 20˚
Volar tilt 0˚ - 15˚
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DISTAL RADIUS FRACTURES Adults
Non Operative Treatment • Below elbow plaster • Re Xray at 1 - 2 weeks
• If no displacement, continue plaster for total of 6 weeks • If displaces – implies fracture unstable – Refer
• Remove plaster at 6 weeks • Assess for clinical union
• Absence of pain at fracture site • Pain at wrist and elbow joints normal due to stiffness
• No Xray required at 6 weeks if clinically united • Gradually progress to unrestricted activities over 4 wks • Wrist stiffness is a big problem – physio if required
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DISTAL RADIUS FRACTURES Adults
When to refer
• Open fractures
• Neurovascular compromise
• Clinical deformity
• Radius AND ulnar fractures – Unstable
• Intra articular fractures
• Variation from normal anatomical alignment
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DISTAL RADIUS FRACTURES Adults
Normal Anatomical alignment
Radial inclination 15˚ - 20˚
Volar tilt 0˚ - 15˚
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DISTAL RADIUS FRACTURES Adults
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DISTAL RADIUS FRACTURES Adults
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ANKLE FRACTURES
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ANKLE FRACTURES Lateral malleolar fractures
Weber A: STABLE
Weber B:
Weber C: UNSTABLE
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ANKLE FRACTURES Lateral malleolar fractures
Non Operative Treatment
1. Weber A fractures – Stable
– Camwalker ± crutches for 6 weeks
– Weight bear as tolerated in camwalker
– Camwalker can be taken off when not weightbeating
– Xray at 6 weeks
– Clinical union = no pain at fracture site
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ANKLE FRACTURES Lateral malleolar fractures
Non Operative Treatment
2. Weber B fractures – Stable if undisplaced and mortice
intact
– Full below knee plaster with crutches
– Re Xray at 1 – 2 weeks
– Plaster for 6 weeks total
– X ray at 6 weeks out of plaster
– Clinical union = no pain
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ANKLE FRACTURES Lateral malleolar fractures
When to refer
• Acutely
– Displaced Weber B fractures
– All Weber C fractures
– Bimalleolar fractures
• Delayed
– Persistent pain
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ANKLE FRACTURES Lateral malleolar fracture
Displaced Weber B
Weber C Bimalleolar
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ANKLE FRACTURES Medial malleolar fracture
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ANKLE FRACTURES Medial malleolar fracture
BEWARE THE MISSED HIGH
FIBULAR FRACTURE!
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ANKLE FRACTURES Medial malleolar fracture
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ANKLE FRACTURES Medial malleolar fractures
Non Operative Treatment
• Make sure you have a full length fibula xray
• Below knee plaster and crutches
• Re Xray at 1-2 weeks to ensure no displacement
• Plaster off at 6 weeks
• Xray out of plaster at 6 weeks
• Clinical union = no pain
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ANKLE FRACTURES Medial malleolar fractures
When to refer
• Acutely
– Open fractures
– Displaced fractures
– Bimalleolar fractures
– High fibula fractures
• Delayed
– Persistent pain
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ANKLE FRACTURES Medial malleolar fractures
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5th METATARSAL FRACTURES
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5th Metatarsal Fractures
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5th Metatarsal Fractures
• Avulsion fracture due to pull of peroneus brevis tendon
• Forced inversion of ankle
• Presents as sprained ankle
• Always xray a sprained ankle
• Treatment aims to prevent ankle inversion
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5th Metatarsal Fractures Non Operative Treatment
• Camwalker ± crutches
• Xray at 8 weeks
• Assess for clinical union at 8 weeks
• Sometimes clinical union may be delayed
• Especially smokers and diabetics
• If still tender, continue in camwalker for further 6 – 8 weeks
• Reassess clinically • If no pain = good
• If painful = Refer
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5th Metatarsal Fractures
When to refer
• Acutely
– Open fractures
– Markedly displaced fractures
• Delayed
– Painful non unions
– Non unions can be painless – leave alone
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5th Metatarsal Fractures
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KEY POINTS
1. Not all fractures need an operation 2. Not all fractures need a plaster 3. If a plaster needs to be done, you can refer to a plaster
technician 4. A picture is worth a thousand words
• Insist on seeing the Xray not just the report • When referring/seeking advice send a copy of the actual Xray
– Email/SMS/Photocopy
5. If something needs to be done, up to 2 weeks delay is OK 6. Children remodel 7. Clinical union is more important that radiological union 8. Clinical union predates radiological union 9. If in doubt, call