Fracture Management
Chantelle:
Welcome to the latest instalment of our Rural Health Webinar series. So this webinar is designed to provide rural and remote GPs with information on how to identify, manage, and treat fracture in clinic, and it will lay the groundwork for the development of skill sets and systems to enable rural GPs to manage simple fractures.
So tonight's presentation will be presented by Dr John Adie, Kerron Bromfield, and Andrew May.
Now, we would like to begin the session by acknowledging the traditional owners of the lands that we are coming together from, and the lands on which this event is being broadcast. I would like to pay our respects to their Elders past, present, and emerging. I would also like to acknowledge any Aboriginal or Torres Strait islander people who have joined us this evening.
RACGP Rural would also like to thank our sponsor, Ochre Health and Recruitment. Established and still owned by two procedural GPs, they operate a network of medical centres around Australia, as well as operating a medical recruitment agency that works with hospitals and medical practices throughout Australia and New Zealand to source and place locum and permanent doctors across a wide range of specialties. So we do greatly appreciate their support of this webinar series.
And just before we start, a few housekeeping things to cover. So all participants are set on mute to ensure that the webinar is not disrupted by background noise. But we do encourage you to use the chat function or the Q and A function to ask questions. When using the chat function, we just 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 or comments.
And finally, the webinar has been accredited for two CPD points. In order to gain the points, you must be present for the duration of the webinar. We do also have an evaluation activity that will pop up at the conclusion of the webinar that we would also ask you to complete. But for now I will hand over to our presenters for this evening. We are starting with Dr John Adie.
Assoc Prof John Adie:
Thanks, Chantelle. A brief introduction from my point of view. I am a New Zealand trained GP and urgent care physician. I have worked in the Barossa Valley as a rural GP training for ACRRM between 2001 and 2006, most recently I am the Australian convenor for the Royal New Zealand College of Urgent Care. I am an adjunct at the University of the Sunshine Coast, and I am working as a GP on the Sunshine Coast.
The reason why I have been asked to present this fracture management course tonight is in New Zealand when I was doing urgent care training and working as an urgent care physician, we always had an orthopaedic surgeon on site every week, and a plastic surgeon and GPs would manage many of the basic fractures that I will be talking about today. In the last eight years my role has been to travel around the country doing deals with state governments to start urgent care centres. And again, we are doing a lot of fracture management. And with my guest, Kerron Bromfield, we set up a fracture clinic in conjunction with Queensland Health which has been going for eight years.
So if I can introduce Kerron. We have worked together for the last eight years in large corporates. She is an operations specialist getting a super clinic started, also the Health Hub, and now she is working in projects around Australia, including the West Sydney Science Park. Also Andrew May, from Essity. Andrew is a physiotherapist but now works with Essity around Australia. I have had a great relationship with Andrew over the last year coming to different states to teach GPs how to manage fractures, and also to teach wound care. So I have asked him along tonight to help with the presentation and teach a little bit about fracture management. The course today that we are doing, it is an hour. It is only enough time to do a brief overview. I would also like to thank University of the Sunshine Coast, where we are tonight. They are strongly supportive of fracture management, and are working on micro credentialing courses as part of an urgent care diploma. And the plan with that is to expand what we are doing tonight, but also teach videos on fracture management and also around the country, have weekends where doctors, nurses, and nurse practitioners learn how to put on plasters like Andrew has been helping me with over the last year.
So, the whole idea of this talk tonight is to encourage you to pick the low hanging fruit as far as fractures presenting to general practice. So we are not orthopaedic surgeons. There is a lot of orthopaedic knowledge that we need to refer to our orthopaedics colleagues for. But there is a lot of fractures that we can manage in general practice if we have a few tools, and if we can do that, we can keep a lot of stuff out of hospital and the ED, and it is better for the patients, better for the health care system, and there is a lot of enjoyment in doing that. But also like to thank Greg Finch, Mr Greg Finch, and Mr Daevyd Rodda. When we started the fracture clinic they were always available with their phones, even if they were in theatre to answer questions about managing fractures, and thus developing the skill set of fracture management.
So I want to start off with three basics. The first is the primary care fracture clinic. And this was done at Ochre Health Medical Centre on the Sunshine Coast. Ochre Health, or Ochre Rural, are our sponsor tonight. And I just had a few questions for Kerron Bromfield, our operations specialist who helped me start up the fracture clinic, and also the super clinic. So, Kerron, can you tell us a little bit about the clinic that you worked at Ochre Health?
Kerron:
Hi, everybody. Welcome and thanks for joining us tonight. So John and I were lucky enough to join Ochre Health to actually set up the GP super clinic down the Sippy Downs which is in the Sunshine Coast in Queensland. So John moved over from New Zealand to do that. I moved from another general practice on the Sunshine Coast. So we were lucky enough to have the opportunity to get that started. The site was planned with functionality around urgent care services which then lead into the fracture clinic which we are going to talk about more tonight. It was a well-planned site. It was built with everything in mind of services that were not being provided on the coast when we came in. We were able to have separate entrances, which lent itself very well for urgent care services, fracture clinics, as well as GPs seeing their usual patients through a separate entrance and the day to day appointments. So we found that worked particularly well. We also had a lot of space to run these additional services.
Assoc Prof John Adie:
And how did you come to get a primary care fracture clinic going? Because that is not a usual thing you do in your general practice.
Kerron:
No interesting. So Nambour General Hospital had looked at their figures and thought that they would put out an expression of interest to the GPs on the Sunshine Coast to see who was interested in participating in offering fracture services from a primary care base with GPs who were specialist trained in the musculoskeletal area, and clinical nurses that also were prepared to do some training. So Ochre Health supported that site for putting in an expression of interest for that. We were lucky enough to get to work with the hospital to provide those services from that site.
Dr John Adie:
And how did you engage the hospital? Because there was quite a lot of engagement going forward with the hospital.
Kerron:
So with regular meetings with the hospital. So it was a really important part of the process that the hospital could assess that the patients were getting the care that they needed, and that we were actually dealing with fractures that were not complex, that were simple fractions or soft tissue injuries that could actually be dealt with by the GPs with the specialist training, and as well as the nurses being able to handle that as well in the absence of a doctor, particularly if the doctor was busy in the fracture clinic that we had nursing staff that could actually assist with that process.
Assoc Prof John Adie:
And the Queensland Health Evaluation report that I have got up on the screen there. What sort of percentage of the fracture clinic actually managed to be managed in general practice?
Kerron:
So when we ran the actual pilot, that was from November 2014 to October 2015, it was approximately 25% of patients were actually seen through that primary care facility.
Dr John Adie:
So that is one in four fractures that would have gone to the hospital.
Kerron:
They would have gone to the hospital otherwise.
Assoc Prof John Adie:
Wow. And were there any concerns about say people, say if their casts went wrong on the weekend, and whether they would have to go back to hospital or whether they could be managed at other places?
Kerron:
We mostly found that we could manage that at the site. There was an occasional patient that would have to be referred back to the hospital, but that was quite minimal, due to the fact that we had GPs with that training and clinical staff, nursing staff, that had actually completed the training. That was quite a rigorous process, particularly for a primary care setting. Again Ochre Health management were very supportive of that process and we were able to update everybody's training every six months. So that was excellent.
Assoc Prof John Adie:
So you actually reached out to people like Andrew to ask them to come in and teach basic plaster skills for the nurses and the doctors.
Kerron:
We did that, and the hospital were also very supportive in offering staff to do that training as well, and to make sure that everybody was up to standard so that the patient always got the right care and was getting sufficient care at the right place. So whether that was a hospital or primary case setting, the patient outcomes were being measured, and they were found to be very, very good.
Assoc Prof John Adie:
And were there any concerns with insurance for staff?
Kerron:
We requested the all of the doctors and nurses working in the fracture clinic actually contacted the medical indemnity insurers, and actually had confirmation in writing that they were covered for their work within the fracture clinic. And there were absolutely no issues with that with anybody getting cover from their medical indemnity insurer.
Assoc Prof John Adie:
Okay. And was the clinic successful?
Kerron:
The clinic was very successful. As we said, we saw approximately 25% of those patients that would have otherwise gone through the hospital system. The measured outcomes and the report, the evaluation report that is in front of us on our screens, showed that we actually had really good results in reducing patient numbers on the waiting list. More patients were able to be seen within the clinically recommended guidelines, and the conversion to surgery rates improved.
Dr John Adie:
And do you think the clinic is reproducible?
Kerron:
The clinic is definitely reproducible, and I understand now that there is a number of clinics doing this, and it has become business as usual for a number of those clinics, particularly on the Sunshine Coast. And I think Ochre actually run two of them at the moment.
Assoc Prof John Adie:
And just with this particular fracture clinic, I remember doing a presentation, and what we found was that 80% of what presented to the fracture clinic you could manage with either casts or moon boots. So common things occur commonly, and if we are able to do the simple things, and according to the rules, not only was it safe, but it was very effective.
So thank you, Kerron. There is a few other resources that I wanted to share with you. First is the Royal New Zealand College of Urgent Care Standard. So in Australia we do not have an urgent care standard yet. So we used the next best thing, which was the standard in New Zealand, which pretty much outlines what you needed for an urgent care centre. But the reason why I bring this to your attention, and you can go and look up this urgent care standard to use this, it is online, is that it tells you the equipment that you need to safely manage plasters. And in the urgent care centres that I have helped start in South Australia, Victoria, New South Wales and Queensland, we have used this. And a number of corporates are using this standard as well.
A few other resources, and I will hand over to Andrew from Essity to talk about basically two products. One is the Gypsona, and the second is the Dynacast.
Andrew:
Get myself off mute. Thank you very much for letting me talk today. We are going to talk a little bit about Gypsona. You might have heard of it as plaster of Paris. That is because it comes from the mines in Paris, and it is still that today. The Gypsona itself, you would have seen it come through EDs in the past as well. It is used for acute immobilisation. You need about ten to twelve layers of the pulp for any major upper limb fracture. With Gypsona itself, it is quite easy to manipulate. Do not be scared of the Gypsona. The only problem is it can look like a bit of a war zone. So make sure you do it in an environment where you are not going to get your cleaners angry that you have wrecked their carpet. But these are some of some of the equipment that you would need to fit your normal standard backslab. So it is a backslab. This is acute immobilisation. We are only looking for 50% coverage. And the reason why we do that is obviously because we need to allow for swelling. It is still in its acute phase. We are not going to the stage where we are doing a full circumferential, lovely coloured full cast. This is for that acute immobilisation stage. This could be before they go to the orthopod to get further investigation. This is on the scene. Get something on them, try to immobilise the joint as best you can.
Rule of thumb. John, if I am going into your slide, just let me know. But rule of thumb is always cast one joint above and one joint below. That is always the standard. And then you are going to have to have other materials which is the Elastolite or the crepe bandage itself. That is going to be used mainly for the moulding, and to get yourself in the right position for those different casts.
So this slide in particular just shows you need a stockinette underneath. You then need padding, so the padding there. Always put the padding on. Put more padding around the fracture site, obviously. You want about two layers up and down, maybe four layers over the actual fracture site. Then you will put a crepe bandage on, as you can see in this picture the crepe bandage is there. So then, that is when you mould it. One consideration when we talk about Gypsona, is it actually takes up to 48 hours to fully set. So this is something that can be a limitation of it. So you do not want them to go test it on their brother’s head straight after you have let them out of the clinic. That is why they often put someone who has broken a bone in the triangular bandage or some type of sling. It is not because it is needed for elevation. It is mainly so that they do not test on their brother's head. The other option that we will show a little bit later, is the Dynacast Prelude, which is used a lot in ED, and also with the ambulance as well.
Sorry about that. I am in the office, and I just turned off the lights. Let me just get them back on.
So here they are here, this is the Dynacast Prelude. So the ambulance use these in their truck, and they use this because it is a lot easier to use on the go. As you can see here, it comes in a large roll. And in that roll is 4.6 metres of this Dynacast Prelude. This is a synthetic version that is worth about 15 to 20 layers of pulp. It already has the padding there, and I cut this about 15 minutes ago when we got online, and it is already starting to set. So this actually can set in air. You see there in the bottom left corner, if you use water as the activation method, it will set in eight minutes. So this is a tool for the ambulance and for practices like GPs. It is a very good tool for you guys, because you can get them in and out and know that the cast is safe, and it is fully set in that eight to ten minute mark.
So this is another option. Both options are fantastic. Both options are very easy to use. I would say this would be quite a lot easier because of its setting. If anyone has played with Gypsona before, there is this time where you are moulding it, and all of a sudden you lose your control of it, and it starts setting on you. So it is a little bit of a skill set. And as John said, hopefully we can do this in person, and you can have that touch and feel or grab someone from ED and have a chat with them about it, and they will show you how it works as well. It is a different type of setting mechanism, but both need water.
Assoc Prof John Adie:
If I could just butt in there. When I spent four and a half years at Royal Adelaide Emergency Department, we used this, and it was an absolutely fantastic product and it was great for managing fractures, and it was very easy and very quick to put on. And I have got another slide there for certain splints, and how Andrew cuts them, which is actually fantastic as well.
Andrew:
So up top, as I said, you can see there is less equipment when you need to use a Prelude. But those three, I will just quickly talk about those three bottom casts there. So yes, those are cut out just as you could cut out the Gypsona, and they are your three most common fractures that EAD see, and consequently, you will see as well. The thumb spica, that is for our scaphoid, the snuff box, you need to just cut the edge off it like that, and then that wraps around the thumb and forms onto the radial gutter the forearm. So you will go from the dip of the thumb to two finger widths below the cubital fossa of the elbow. That is your parameters of your thumb spica cast.
You then have the boxer’s splint. Now for those GPs working on Friday, this will be a popular one. This is your Friday night special when, you know, you got someone who has had a fight on a Thursday, Friday night, and these come in. So these are what we call the posi. You might have heard of this, the posi splints. So the posi splint, we are going through it quickly, but this is more of an overview. So we go about 60 degrees wrist extension, 45, 60, depending on what state you live in, and 90 degrees finger flexion. So we call it the duck bill, the Lleyton Hewitt, whatever you want to call it. This is the position of safe immobilisation. Whenever you are moulding them, and this is in the moulding stage, they are moulded in this direction because it actually feels good for the patient as well. So do not be afraid to really get in there and mould it. Alright. So for the parameters of this, this time it will be the ulnar gutter, and again, you will go from the dip to two finger widths below the cubital fossa, and on the ulnar gutter. Some people like to do a full posi, if you are not sure which finger, then you can do a full posi just like that on the volar aspect just like that. Okay?
Then, the last one is just your simple distal radioulnar fracture. You might be a bit unsure as to what might be fractured. Is it a carpal? What might it be? So that one we just cut out the space for the thumb, then follow the metacarpal head-line. That is where you see that little rounded edge on the top. Therefore we can still oppose a thumb, as our fracture site is here. Go in a joint above go in a joint below, fracture site. Okay? Again, I apologise for rushing through it, but they are going to be the main ones you see. And as John said, this skill set is growing, and it is so important that you guys can try to pick this up. It is not a hard skill set to have. As John said, I go to all different states and teach this. I am from New South Wales, and it is mainly a physio remit. You will go to South Australia, and the orderlies will be putting on the casts. It is all over the place who can do it and how they do it, but it is a skill set, but it is a great skill set to have in your practice. So anything that we can do to help and John can do to help, just please let us know.
Assoc Prof John Adie:
Thanks, Andrew. So on to a few resources, because when you know how to put on casts, you have got nurses that can do that, it is important to have resources that you can refer to. So I have just put up a few slides on the common resources that I use. Orthobullets absolutely fantastic for all sorts of fractures, and I will be referring to the website tonight. The second is the Royal Children's Hospital in Melbourne. You will see outlined there in the yellow, these paediatric fracture guidelines for emergency departments, also for fracture clinics, and there is also resources that you can give to patients which makes you look good. There is also Physiopedia and Radiopaedia. These are tremendous websites that talk about interpretation of x-ray, and also physio exercises. And of course McRae's Practical Fracture Management. This is like the Bible for managing factures, and we have been using this for the last 25 years.
A few of the basics that I wanted to draw you attention to. The first is the whole idea of the fracture haematoma. So there is three main phases to fracture healing. Firstly, the inflammatory phase, and that is hours to days. And basically fractures cause fracture haematomas. And what you get is the cytokines, the prostaglandins, the gross factors released into the fracture haematoma, and you get fibrovascular tissue forming.
Then there is the reparative phase, and that is days to weeks, and callouses are laid down. And at the start the callous is quite soft and the fracture can be moulded, but as time goes on it becomes a lot harder. So if you do not get the position right, especially approaching two weeks, instead of being able to remould it, you might have to refer to have it re-broken.
And then there is the remodelling phase which takes months to years and the callous is removed and replaced by new bone. So you can see the example there of a mid-humerus fracture in a child, and there is a big explosion of fracture haematoma, and then after six weeks you are back to having a normal fracture. So it is good to keep that in mind when we start to manage fractures.
A few other basics. I was always taught in the fracture clinics in the urgent care, that it is good to see the patients obviously when they come in. Of course you are seeing them then, on day seven to ten, and at the end of the fracture management episode. So I have usually followed those rules through my career. And for relevant fractures, I have x-rayed them, and that is a medicolegal thing as well, just to show that the fracture has healed in the right place. Second is to document the examinations of the joint above and the joint below, as well as the neurovascular status. I remember earlier in my career where you get a fracture, maybe distal radius, but you do not check the elbow, and there is also a fracture there as well. So I always check the joint above and the joint below. Beware Salter-Harris III to V, and also open fractures. So Salter-Harris I to II fractures, if they are non-displaced, very happy to manage those, but as the numbers go up, so does the complexity and the risk to future growth. Also open fractures. If a fracture is open and the skin is broken, we do worry about infection down the track, so sometimes we have to refer those for washouts. Fourth, you might get a letter from the Chief Medical Officer of Health for ordering more x-rays than your peers.
This happened in New Zealand in the 1990s when urgent care and fracture clinics took off, and I am also having some colleagues doing urgent care and fractures finding that. So do not be surprised if that happens. But keep doing what you are doing. The other fact I wanted to share is, ideal management of fractures involves a physiotherapist, and then New Zealand where I have done most of my training, the government pays for accidents and physio for that. So the patient has very little out of pocket cost. So in Australia, for most it is cost prohibitive, and because they have not had the injury for six months, the care plan does not cover. So what I will often do is to give Pdf advice. We are hoping to develop advice sheets on that, that people can share.
So what I want to do today is to talk about five upper limb fractures and three lower limb fractures that are very common presentations to the fracture clinics, and we will see how many of these we can get through tonight. Obviously I appreciate your feedback, because we want to work on a course where we can flesh this out a bit more, and if there is any questions we will talk about those at the end.
So, starting from the top, one of the most common fractures that we manage in the fracture clinic is the clavicle fracture. There is a bimodal distribution to that with two peaks. So men under 25, especially kids from sports injuries, and patients over 55 from falls. So it comprises 10% of sports related fractures, and surprisingly, it is the third longest time to return to sports with 20% of athletes not returning to sports. As far as the anatomy is concerned, 80% of fractures are in the middle segment, where I am outlining now, and you can see that the bone is very narrow there, and there is a lack of support from ligaments and muscles. 12% to 15% of clavicular fractures are in the lateral area where there is a lot of ligaments.
So a little bit about anatomy. Here is the shoulder joint. You have got the coracoclavicular ligament and the AC joint capsule. Common mechanisms of injury are falls and direct blows to the shoulders. And when I look at examination, I am looking for complications and associated conditions. So the big ones I am looking for is the clavicles, the open fractures, skin tinting, because that indicates impending open fracture. The subclavian artery and the brachial plexus injuries, the rib fractures, pneumothoraxes, and closed head injuries. When I am looking at x-rays, I am looking at fractures that I can manage, and I am also looking for complications that I do not want to miss. So in adults we are picking the low hanging fruit here. The middle third fractures. We are able to manage fractures that are less than two centimetres shortened and less than two centimetres displaced. Most angulated fractures we can manage if they are not tented. Obviously they need to be closed, and neurovascularly intact. And then the lateral third, the Neer types one and three are the ones we can manage if they are minimally displaced.
For children we, if the fracture is not off-ended and not tender, we can manage that. And the un-displaced Neer’s types one, three and four. So here are a few examples that Lumus Radiology have kindly gone through and provided for us. So here is a basically an acute, minimally displaced fracture in an adult involving the left mid-clavicle. So this is a barn door one, that general practice can manage, which is good. Here is a Z-type fracture, which is comminuted, and it has more than two centimetres overlap, and there is a lot of displacement there, so not something that I would be wanting to manage in general practice. I would want to refer that up the food chain.
Here is a Neer’s type one clavicle fracture, and you can see the little picture up the top here. And basically it is an extra-articular fracture which is lateral to the coracoclavicular ligament with an intact conoid and or trapezoid ligament, and minimal displacement. And the x-ray shows kind of the same thing. So that is a fracture that I will be very happy to manage in general practice.
Here is a type B Neer's fracture, and the conoid or the trapezoid ligament is torn as per the cartoon there. This is an unstable fracture, and has a high non-union rate so we would definitely send that to the orthopaedic surgeon, and the orthopaedic surgeon has surgically repaired this fracture.
Here is a fracture of the proximal right clavicle in a child with superior angulation after a fall from a trampoline. This is a fracture that I would be very happy to manage in general practice, because there is no tenting.
Here is a fracture, a transverse mid-clavicle fracture, certainly superior angulation and tenting, and because of the tenting the fracture was surgically managed. This is a Neer’s type four growth plate fracture, and you can see from the cartoon there that there is an intact conoid and trapezoid ligament, a little bit of displacement there, but only minor. It is a stable fracture, happy to manage it in general practice.
So when we are talking about management, conservative management in adults would be about two weeks, just under two weeks in a sling or a shoulder immobiliser with limited movement. The three to six weeks would be the reduced use of the sling, and then you start getting the shoulder moving. And then you get the strengthening exercises starting after three months. So about 90% strength at three months. So for the rugby players coming in, I tend not to encourage them to go back until after three months.
Here is the shoulder immobilisers that we often use, that Andrew has helped us with. I will pass over to Andrew to make a comment on these.
Andrew:
This sling is very easy to use. Two straps, one around the waist, one over the shoulder. It is a Velcro base, so you can fit this to the patients. There is, as you can see there in the little picture four, a place where you can hold the thumb to offset the loading and the weight of the hand as well. But the strap across the shoulder you can raise lower. But there are all different ways in which you can and put a sling on. There is the double one, so it is just having the full support of the forearm to take the load and the pressure off the clavicle itself.
Assoc Prof John Adie:
Thanks, Andrew. And for children, and I get this off the Royal Children's Hospital in Melbourne’s website. So for middle third clavicle fractures, if the child is under 11, and it is un-displaced, the fracture, sling for two weeks, then mobilisation according to pain tolerance. Return to sport in six weeks. And their advice is no follow up or x-ray unless there is ongoing pain, and it is fantastic to have this type of input because, you know, in past-times we x-rayed at seven to ten days, and I would have seen the patient at six weeks. If the patient is over 11 or there is minimal displacement, I would certainly see the patient at seven days, and at 28 days with re-x-ray if there is ongoing tenderness. Off-ended I refer to the ortho service. The lateral third un-displaced, I see them a bit more often. I would repeat the x-ray in two weeks and return to contact sport would be eight weeks.
I want to talk a little bit about operative indications, because there are absolute ones like skin tenting and open fractures, and subclavian artery or vain injuries, floating shoulder is another one when you get a scapular fracture as well as the clavicle fracture and the non-unions. But there are also relative ones, and I look at the last 25, 30 years of my career at the times that I have run for advice, for orthopaedic surgeons, and sometimes some orthopaedic surgeons will be very happy to have conservative management of displaced fractures, but others will not, and the way I see it is, I am a GP, I have got a certain skill set, and I am going to pick the low-hanging fruit according to the advice that I have from my textbooks and around Australia, and if it is outside of that I will get an orthopaedic surgeon or registrar to advise me. And in recent models that we have been working on in Adelaide the orthopaedic services are very happy to take texts of x-rays and advise over the phone.
Then there are relative indications where there might be a bit more displacement or brachial plexus injuries, seizures, closed head injuries, those sorts of things. Always complications, non-operative, you have got the non-unions, especially if there is lots of displacement and shortening, the mal-union, the poor cosmesis, and sometimes with patients, they do not like the idea of a bump, but if they get an operation they get a scar. There are also complications of operative injuries like the non-union, the hardware prominence where they need to have it replaced, taken out, and the neurovascular injury. And this is a real risk, I have heard of patients passing away from this, so certainly not one to be taken lightly, infection, pneumothorax and adhesive capsulitis.
So I have just added a slide at the end that compares the MBS and what they pay for a fracture management episode for clavicles compared to ACC in New Zealand, and you will probably find through this talk that the government in New Zealand pay a lot more for fracture management, which is why general practice and urgent care clinics manage a lot more of the fractures. So that is the first one, clavicular fractures.
The next common fracture that we see at the fracture clinic is the supracondylar fracture with children, and this is a common childhood fracture, especially aged five to seven. I will just remind you of some of the anatomy that is going past the elbow joint. There is the brachial artery, there is the radial, medial and ulnar nerve. Also in the lateral view you can see the brachial artery is anterior there, and we have always got to make sure that we test for neurovascular status, because we do not want any of these important structures to be damaged, and we miss that. So in the anatomy we look for the sail sign, and pretty much it is also referred to as the fat pad sign, and it is a silhouette sign similar to the picture of the spinnaker on the boat there, and pretty much if you have a supracondylar fracture, or a radial head fracture which is intraarticular, you will see the fat pad sign. In fact, if you see the fat pad sign but there is no fracture in a child, it is most probably going to be the supracondylar fracture that is not displaced or an occult one. In an adult, it is more than likely going to be an occult radial head fracture.
Here is an example of the sails sign in a supracondylar fracture with anatomical alignment.
So common mechanisms of injury. As the elbow straightens out, the olecrenon wedges into the humerus and causes the fracture. There are a few complications that we have to look for, firstly neuropraxia, and most of these results spontaneously. So we are looking for the anterior interosseous nerve, that is the commonest in neuropraxia. But we are also looking for median, ulnar and radial nerve injuries. Vascular compromises is 5% to 17%. I have seen a little bit of that. And the importance of examining the joint above and the joint below is because, especially in these fractures, is that you can get ipsilateral distal radial fractures.
When I am looking at x-rays, I am looking at the Gartland classification, so 98% are extension injuries where you have got anterior displacement, 2% are flexion injuries where you get posterior displacement. The three types of Gartland classification is a type one injury, un-displaced fracture. Type two is an angulated fracture where the posterior cortex, just to highlight that, is intact. And type three, you get a displaced fragment posteriorly, with no cortical contact. We would not be managing this in general practice.
We are also looking for Baumann's angle, and that is measured on the AP radiograph with the elbow in full extension, 64 to 81 degrees is normal. We would normally compare it to the other side if we were concerned, and differences of more than five degrees is abnormal. Here is a Gartland type one un-displaced supracondylar fracture. We manage those in general practice.
Here is a type two, but the anterior humoral line there in the red does not intersect with the capitellum, meaning we need to send this fracture for reduction. Here is a Gartland type three, it is certainly displaced. We would need to refer this fracture for reduction. And here is the fracture which was K-wired. Here is an example of a comminuted fracture of the right humerus, and the fracture has an increased Baumann's angle, so we would send this for an opinion.
Here is an example of a supracondylar fracture where the child fell off a trampoline, a displaced supracondyle fracture. CT would be advised, and discussion with ortho.
As far as management of the fractures in general practice, we can manage Gartland type one and above with backslab and 90 degrees of flexion, with a sling for three weeks, and it is important not to manage them with any basically reduced flexion like 80 degrees, 70 degrees, because you can potentially cut off blood supplies. And the Gartland type two, if the anterior humoral line is intersecting the capitellum, we can put patients in backslabs for three weeks, but we certainly x-ray them in zero, one, three and six weeks. We do not want late slips. But we start gentle range of movement at three weeks.
I have got a picture here of the plaster that Andrew will just talk about now.
Andrew:
So, yes. This is actually an example of the Prelude. So it is the cut version. Again, getting that arm in the right position, you can just pinch it at the elbows to help with the fitting around the elbow. Some people you might hear they will do the U-slab up that way as well. It is up to you depending on any of your imaging that you have got. And then again, putting them in a broad arm sleeve to maintain that position, but obviously the cast will be set in the position of best fit.
Assoc Prof John Adie:
Thank you. Complications, mal-union, especially a varus malalignment. We certainly want our fractures angulated in the right way going forward. Stiffness is important in the elbow, and also neurological injury. And just comparing MBS to ACC and New Zealand, a big difference between the MBS at 100% would be close to 320. In New Zealand it would be 470 plus GST, and a lot more fracture management happens because of the funding on the other side of the Tasman.
So the third fracture we want to talk about is the distal radius fracture, another common presentation to fracture clinics. In fact, probably most of our fractures that presented to the fracture clinic was distal radius, and also to the urgent care centre that we have been running over the years. So 18% of all fractures to adults, more females than males. Half of them are intraarticular, and there is a high incidence in women over 50. A DEXA scan is certainly recommended. With distal radius fractures osteoporosis is predictive for subsequent fractures, so we certainly do not want another fracture happening after the first one.
So, a little bit of anatomy. So the distal radius takes 80% of the axial load of the wrist, which is why it is a common injury as far as fractures are concerned. So the scaphoid links with the scaphoid fossa, the lunate with the lunate fossa, and the distal ulnar via the ulnar sigmoid notch here. There are three columns, firstly the radial column, including the radial styloid over here and the scaphoid. The second is the intermediate column, connecting with the lunate, and the last is the ulnar column which includes the distal ulnar and the triangular fibrocartilage which is also injured quite frequently. Commonly it is a fall on an outstretched hand, and younger patients from high-energy mechanisms and older patients just from a fall on an outstretched hand.
We are looking for soft tissue injury complications. The triangular fibrocartilage, the scapholunate ligament is an important one not to miss, and the lunotriquetral ligament. When we are managing distal radius fractures in children, I refer very often to the Royal Children's Hospital in Melbourne website, because you will notice there in the zero to five year group you can accept 20 degrees of angulation. In the five to ten years it is less at 15, and then 10 to 15 years, it is less than 10 degrees. So these are very helpful, you know, mathematics to use and manage in practice.
So when we are x-raying we are looking for fractures we can manage, and here is an example of a Salter-Harris type one fracture. Unfortunately this one is displaced, so we need to send that up the food chain. But we manage a lot of Salter-Harris type one fractures in the fracture clinic, and what I have noticed over the years is children will come in, they will have very tender growth plates. The x-ray will be normal, and if I do not manage them in the cast, a great deal will come back in the next few days, because they will not be able to sleep. So you know, I often found at the 10 day mark, that about 80% of the patients that I was managing with Salter-Harris one would settle down, but the odd one would continue and need four weeks in the cast.
Here is a Salter-Harris two type fracture of the distal radius with dorsal displacement. Unfortunately, I would not be able to manage this one in general practice, it would need to be reduced. Here is an un-displaced torus fracture involving the metaphysis, definitely one we can manage in general practice. And here is a Salter-Harris four fracture above and below the joint line. Unfortunately, because of the displacement, and you will notice here it is intraarticular, and there is some displacement here, it would need orthopaedic input.
When we are managing distal radius factors in adults, it is helpful to look at the normal anatomy and see the radial height here is 11 millimetres, the inclination is 23 degrees, and the palmar tilt is 11 degrees. I go to Orthobullets which also gives me an acceptable angulation for adult distal radius fractures and what I can accept, and what I cannot accept. The great thing about this is that it even talks about step ups and changes and shortening, and what I can accept as far as angulation is concerned.
So here is an un-displaced fracture of the right distal radius. No fracture extension to the articular margin, and it was anatomically aligned so certainly a fracture that we can manage in general practice. Here is a fracture of the right distal radius. Unfortunately, I do not have the AP, but it had 30 degrees of dorsal angulation, so this would need to be reduced. Certainly something that we would do in rural general practice, and that is what happened.
Sorry I am getting my slides mixed up. So here is a comminuted fracture through the distal radius with some dorsal displacement and angulation. I would not be able to accept that, so send up the food chain to ortho. Here is another fracture of the distal radius, with fracture extension into the articular margin, and some angulation. This fracture was reduced in ED, and an acceptable position, so certainly something within the skill set of a rural GP.
A few complications that we look for that we do not want to miss. Here is a die punch fracture, so it is a depressed fracture of the lunate fossa, where it articulates with the distal radius. So we would have orthopaedic opinion for that. Also for the Smith’s and the Barton's fracture. So Smith's is reverse Colles, and the Barton’s is a fractured dislocation of the radiocarpal joint with often intraarticular involvement.
So the last one is the Chauffeur's fracture, and it is an isolated fracture of basically the radial styloid. It is uncommon, but these are often displaced, and they might be associated with scaphoid and ligament injury which you certainly do not want to miss, so I would always involve an orthopaedic surgeon, even if it was on the phone.
In children, distal radius fractures. The non-displaced, Salter-Harris type one and two, above backslab, removable splint for four weeks. The metaphyseal fractures below backslab, removable splint for three weeks, and if they are complete but un-displaced or minimally displaced, we would use a cast for six weeks.
Distal radius fractures in adults. Backslab or split cast, change the plaster at seven to ten days, hopefully into fiberglass. Remove the cast in six weeks. And Andrew has kindly done a slide for us of volar backslabs.
Andrew:
So yes, just quickly here. I am showing the way that it is rolled out. So you roll out the amount of layers that you need. You then activate it by wetting the Gypsona. I put it in this little pattern. Soak it through the water, make sure you put on your stockinette. Then you put on your bandage. Then the cut out mould which we saw in one of the original slides. And again you mould it, and the picture on the bottom right is the position of safe immobilisation in a wrist neutral position.
Assoc Prof John Adie:
Thanks, Andrew. And then we look for the complications. It is good to know about them, because sometimes even if you do everything right, you will get some complications. So mal-union, compartment syndrome, chronic regional pain syndrome, Dupuytren's contracture. Thankfully not too much in the way of nerve pathology. But we do have to watch for carpal tunnel nerve complications and the capsular contracture. When we compare New Zealand to Australia again, close to 180 dollars in Australia, and New Zealand the same would be just over 400 dollars plus GST.
So the fourth upper limb fracture that is common is the metacarpal fracture, and this is the most common of the hand fractures with 40% of all hand injuries, and of course the most common site is the fifth metacarpal. A lot of these, as Andrew was saying on a Saturday morning and Sunday morning at the ED. So when we are looking at anatomy, we have got the head, the neck, the shaft, and the base, and the management of these fractures depends on where the fracture is along the metacarpal. So common mechanism of injury is being punched in the face. Some complications that we need to watch for, is basically the angular and rotational deformity. So when I am examining patients with these types of fractures, I will actually get a pillow, and if I can just show my hands here, I will actually get the patient to slowly bend and see if there is any angular or rotational deformity. And sometimes, if the finger bends right around, even if the x-ray looks okay, I will be on the phone to my orthopaedic colleagues to help.
Here is a see a slide from Orthobullets which talks about acceptable angulations for metacarpal fractures, and if I can just draw your attention to the fifth metacarpal. This is the neck angulation. I remember when I was earlier on in my career in ED, I would always try and reduce these after an ulnar nerve block, and re-x-ray them, and it would look absolutely fine. But when I went back to New Zealand, and I was working in the urgent care clinic and the orthopaedic surgeon came up to me and he said I used to do that, too, but almost all of them actually go back to what they were before. So now I follow these guidelines, and well, this is what I tell the patient, there will be no deformity as far as moving your hand is concerned. But if I am to have a look at your wrist, there will be a lack of a bump there. So yes, most people are happy, and I can talk about that.
So here is an oblique fracture that is extra-articular through the fifth metacarpal, and it is near anatomic alignment with a bit of soft tissue swelling. Certainly according to those rules, I would be very happy to manage that in general practice as I would with this fracture, which is a minimally displaced, oblique fracture through the shaft of the third metacarpal. No dislocation. Here is a fracture of the distal right fifth metacarpal with approximately 30 degrees angulation, which comes in at less than the guidelines, which is 50 to 60 degrees, that we can accept. And here is a spiral fracture of the proximal third metacarpal with minimal overlap, and I would certainly be happy to manage this in general practice.
When we are managing metacarpal fractures it is good to buddy strap the fingers as well, because that reduces the risk of rotational deformity. I will cast and splint for about four weeks in the position that Andrew described before, and I would just be careful to always buddy strap. And Andrew has done a couple of nice slides for us for boxer’s fractures, and also with the Dynacast for other metacarpal fractures. Over to you, Andrew, for that one.
Andrew:
Yes, so you can see the buddy system there getting that fifth and fourth together, and again putting in that 45 to 60 degree wrist extension, 90 degree finger flexion using the same method of wedding lining, putting the padding on, and then putting the bandage on to mould them into that position.
Assoc Prof John Adie:
Awesome. And then you have got some Dynacast there, so you can manage them either with PRP or Dynacast, and you have got a slide on the Dynacast there.
Andrew:
So same thing. So for this one, this would be for your full volar slab. So this is where you might be unsure as to which finger, if you do not have access to your x-ray facility at that time of day that they are in, you are unsure but you know there is at least one you can always do the full volar slab to get them into that same position of safe immobilisation.
Assoc Prof John Adie:
Complications is stiffness. So we like to get the fracture moving is as quickly as possible, and then, compared to New Zealand, close to 120 dollars Australian is what we would get paid here. In New Zealand you would get close to 410 dollars plus GST.
So the last fracture we are going to get through tonight is finger fractures, and these are also very common, especially the fifth finger. More males than females, and more distal is more frequent than middle, which is more frequent than proximal. So pretty much for anatomy for the distal phalanx, you have got the tuft, the shaft and the base, and for the proximal and middle phalanx you have got the head, the shaft and the base. A little bit of anatomy, you will remember with the flexor tendon, you have got FDS, and that is joining into the volus side of the middle phalanx and the FTP on the volus side of the distal phalanx. With the extensor tendon, you have got the tendon slip onto the dorsal side of the second metacarpal and the lateral slips, and they insert into the dorsal side of the distal phalanx. Basically we classify all the common mechanisms of injury according to age, so sports in younger people, machinery in working age people and falls in older people.
We are always looking for angular and rotational deformity, nail bed injuries and neurovascular status, especially with cuts because we do not want to miss that. With finger fractures, it depends on where the fracture is. If you have a proximal or middle phalanx there is three types. There is the stable with no displacement. There is the unstable unicondylar and the unstable bicondylar. It is important to pick these because over the years I have seen fractures that have gone wrong, and people have been left with cosmetic deformity. So if you follow the rules, it all turns out well or usually turns out well. Neck and shaft fractures can be long or short oblique, spiral or transverse, and I have got a few examples of fractures here. Here is a transverse fracture of the proximal phalanx. It has got three millimetres of palmar displacement. This fracture would be reduced. Here is a fracture, a comminuted intraarticular fracture, of the proximal phalanx of the left finger, and this would be referred to the surgeon because of complications or potential complications. And here is a picture of it being reduced.
Here is an acute spiral fracture of the proximal phalanx of the left finger with no intraarticular extension. It was reduced numerous times and this was the result in fracture clinic. Here is a comminuted spiral fracture with minimal displacement. This is certainly a fracture that I would manage in general practice. And here is a fracture present in the neck of the middle phalanx, the left ring finger, certainly be able to manage this in general practice.
The proximal base fractures, there is the extra or intraarticular ones, there is also the partial or incomplete articular fractures. So, this would be a partial on the volar side. This would be a complete on the dorsal and volar side. And here is a fracture involving the proximal phalanx of the left little finger reaching the articular surface, because there is minimal displacement, and knowing it about rotational deformity, I would be happy to manage this in general practice.
When we are looking at x-rays we are looking depending on the anatomy, so on the tuft fractures we are looking for crush injuries, and when we are examining, we are also looking for lacerations of the nail matrix. The base can often be unstable, and we are especially concerned if there is more than 20% of the articular surface involved, and also the Seymour fractures in kids where you get basically growth plate fractures and deformity there. So that would present as a Mellor deformity.
So here is an example of an open fracture of the left distal phalanx with a segment that is displaced. Also, if you leave that, the finger almost has an extra joint, so these need to be referred for K-wiring. Here is another open fracture of the middle distal phalanx with separation and angulation. This will need to be referred to the orthopaedic surgeon. And here is a displaced intraarticular evulsion fracture the dorsal aspect of the finger. Unfortunately, this would also need to be sent to the orthopaedic surgeon.
I see that we are at eight o'clock now, so what I will do is I will finish on the Seymour fracture, which is the Salter-Harris type one or two fracture of children of the distal phalanx. It is important to have involvement with the orthopaedic surgeon in these because there will be long term deformity, if you do not. S
So that wraps it up for us at eight o'clock. I am very grateful for RACGP to put on the session. I am very grateful to the University into my co-presenters Kerron and Andrew, and Chantelle for leading the session. I appreciate your feedback, and we are certainly wanting to develop some teaching materials down the track and also put on some courses around Australia through Andrew at Essity to encourage fracture management in general practice. So thank you so much, everybody, and back to you, Chantelle.
Chantelle:
Great. Well, thank you very much, John, Kerron and Andrew, for a very informative session. So just before I finish up RACGP Rural would again like to thank our sponsor, Ochre Health and Recruitment. And finally, just thank you to all of our attendees for joining us this evening, and just to remind you to please complete that evaluation form that will pop up in a new window in just a moment once the webinar session closes. It takes no more than a minute to complete. Certificates of attendance will be available on your CPD statements next week, but for any non-RACGP members who would like a certificate of attendance, please email [email protected]. But on that note I would like to again thank everyone and goodnight. We will end the webinar now. Thank you.