Basic Fractures

In this episode of PodMD, Orthopaedic Surgeon Dr Paul Thornton-Bott will be discussing the topic of basic fractures, including what a basic fracture is, how a GP can indentify a basic fracture, where to refer and more.

• Transcript
  Please note this is a machine generated transcription and may contain some errors.
  *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

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  Today I’d like to welcome to the PodMd studio Orthopaedic Surgeon, Dr Paul Thornton-Bott

  Dr Thornton-Bott is an orthopaedic surgeon. His specialty/ special interest involves arthroplasty of the Hip and Knee, arthroplasty revisions, computer navigated, and robot assisted surgery and a focus on trauma; fractures and neck of femur outcome.

  Today, we’ll be discussing the topic of basic fractures and when to refer.

  *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
  If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

  Paul, thanks for talking with us on Pod MD today.

  Paul: You are welcome, thank you for having me.

  Question 1
  The topic of today’s discussion is basic fractures. Paul, can you describe for our listeners what a basic fracture is?

  Paul: The fractures most GPs are commonly presented with will be fractures of the wrist, hand, ankle or foot. Typically, the patient will present with a history of a minor fall, twist, sporting injury etc. and there will often be a history of pain, trouble with weight bearing or use of the limb along with swelling and or some bruising. Most patients will have put up with this for a few days before presenting to the GP, and it is usually because they don’t believe they have done any major injury and don’t wish to waste either their time, or that of the Emergency Departments with a something that could be a simple sprain. It is rare for patients to present to GP practices with major fractures, they usually know that they need to get to ED.

  Question 2
  How can a GP compare a basic fracture to a more serious fracture? What should they be looking out for?

  Paul: If a patient presents to a GP with a history of significant force, such as a motor vehicle accident, a fall from a height greater than 1m these patients should be referred to ED. Very simply, the GP should look for any deformity of a limb, this includes rotational deformity of fingers. Look for wounds over a potential fracture, which may then be an open or compound fracture Severe swelling, severe pain not controlled with simple analgesia, and any discolouration or altered sensation of a limb. Any and all of these indicate a more serious injury and should be referred to ED. The GP does NOT need to arrange an xray for these patients, as delay can sometimes be dangerous for the patient. The patient will get an Xray on presentation to ED.

  Question 3
  Can patients get a serious fracture without major trauma?

  Paul: The GP must always suspect a fracture in an Elderly patient who presents with musculoskeletal pain, as fragility fractures are unfortunately very common and can occur with seemingly minimal trauma in a patient with osteoporosis. Another thing GPs should have in the back of their minds are pathological fractures, that is a pathological process that weakens the bone such as in cancer. Again, anyone over the age of 45 with limb, pelvic or spinal pain with minimal or no trauma should be investigated for these fractures.

  Question 4
  So, going back to the common basic fractures, when should GPs request an x-ray, and what should they ask for?

  Paul: So, if a patient gives a history of an injury, if they have swelling, bruising and importantly tenderness of the bone at the site of injury they should get an xray to exclude a fracture. A patient struggling to put weight on an ankle or foot should also get an xray. A very simple guide to x rays is to ask for AP and Lateral views of the affected area. If the pain is close to a joint, ALWAYS request an xray of the joint.

  Question 5
  What about lab requests?

  Paul: These are usually unnecessary. However, in patients with suspected Osteoporotic or Pathological fractures a basic set of blood tests will be a good start, FBC and EUC and Bone Profile. More specific labs will be requested by the ED team and the Specialist managing the patient.

  Question 6
  And Paul, what should the GP do with the patient before they go off for an X Ray?

  Paul: If the patient is in pain, doesn’t want to move the limb or walk on it, then the best thing the GP can do is give analgesia and arrange some sort of immobilisation. If it’s a wrist or hand, put a splint or a cast on. If an ankle or foot, get them into a CAM boot and give them some crutches. Simple analgesia is required, but it is the immobilisation that will really be useful.

  Question 7
  What does the GP need to be looking for when the Xray comes back?

  Paul: The reporting is usually very thorough but can sometimes be delayed, so if the GP looks at the images before the report comes back they can assess them and may be able to start the referral process straight away, or importantly can reassure the patient if no fracture is seen. In general terms, anything other than mild angulation should be referred. Some angulation is acceptable in younger children as they remodel, but older kids and adults do not have the same potential. The GP must refer to any fracture that extends into a joint as Intra-articular fractures are far more serious and, if missed, can lead to early onset post traumatic arthritis.
  Displacement, shortening, translation and rotation are all terms that should stimulate a referral, especially in a hand injury.

  Question 8
  What about Greenstick fractures? These are very common injuries. How should the GP manage these basis fractures?

  Paul: That is correct Sean, a greenstick fracture is an incomplete bending fracture, and a torus fracture is a cortical buckle fracture and both are very common in children who often present to the GP with several days of discomfort after a seemingly minor fall. In general, these are stable fractures, usually in the wrist or forearm. If angulation is less than 10 degrees, these can be safely managed in a cast for 4-5 weeks. Anything more than 10 degrees should be referred to the Orthopaedic Specialist.

  Question 9
  Paul, how can GPs support both Allied Health and surgeons when they see a patient with a minor fracture?/strong>

  Paul: The first priority is patient safety and reassurance. A clear referral letter is important both to Physiotherapy and Surgeon. The physio will need to see the patient in the initial stage, before the surgeon, to provide the splint, cast, boot crutches etc which give that initial immobilisation or support to the injured limb. I find it useful as an orthopaedic surgeon to both see the xray report and also where the imaging was done. We all have online access to imaging now and it helps to be able to look at an xray when the referral is received to best plan follow up.

  Question 10
  What if no fracture is seen?/strong>

  Paul: Any injury involving a joint may involve ligament injury only but can be equally disabling for the patient. Also, some fractures are not immediately obvious and are only seen a week or more after the injury, for example scaphoid fractures. Referral to physiotherapy for a splint or boot is an ideal initial management strategy in these patients. Follow them up a week or so later and if still in a lot of pain then it’s a good idea to refer on for Orthopaedic review. Specialist scans such as MRI may be required to identify some of these occult fractures and soft tissue injuries. Significant ligament injuries may also need surgical intervention and are often best performed in the early period.

  Concluding Question
  Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on a basic fracture

  Paul:
  1. Identify those features that need to suggest a more serious injury and direct the patient to ED.
  1. Visible deformity
  2. Skin breaks over site of injury
  3. Altered sensation or concerns for vascular compromise
  4. Excessive pain

  2. Treat the patient’s injury first. Provide analgesia and then early involvement with allied health for immobilisation and walking aids. Then get an xray.

  3. Minor angulation, especially in greenstick or torus fractures can be managed in a cast for 4-5 weeks. Anything else should be referred to the Orthopaedic Surgeon.

  Sean, my final message is this: – If you are unsure about an injury please refer the patient. As an orthopaedic Surgeon I would always prefer a GP to make an early referral if they are unsure even if it turns out to be something simple like a sprain! I can always reassure the patient and send them off to Physio, whereas managing a fracture referred at a late stage can sometimes be difficult.

  Thanks for your time and the insights you’ve provided.

  Paul: You are welcome, thanks you for having me