Fracture Management for Primary Care: Expert Consult, 3rd Edition

392 Pages·2011·13.66 MB·English

by  M. Patrice Eiff MD

Fracture Management
for Primary Care

THIRD EDITION
Fracture
Management for
Primary Care
M. Patrice Eiff, MD
Professor
Department of Family Medicine
Oregon Health and Science University
Portland, Oregon
Robert Hatch, MD, MPH
Professor
Department of Community Health and Family Medicine
University of Florida
Gainesville, Florida
Mariam K. Higgins
Medical Illustrator
Portland, Oregon
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
FRACTURE MANAGEMENT FOR PRIMARY CARE ISBN: 9781437704280
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
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Practitioners and researchers must always rely on their own experience and knowledge in evaluating
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Library of Congress Cataloging-in-Publication Data
Eiff, M. Patrice.
Fracture management for primary care / M. Patrice Eiff, Robert Hatch.—3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4377-0428-0 (pbk.)
1. Fractures. 2. Primary care (Medicine) I. Hatch, Robert, 1957- II. Title.
[DNLM: 1. Fractures, Bone—diagnosis. 2. Fractures, Bone—therapy. 3. Primary Health
Care—methods. WE 180]
RD101.E34 2012
617.1’5—dc23
2011017590
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contributors
M. Patrice Eiff, MD Adam Prawer, MD
Professor Family Medicine Resident
Department of Family Medicine Department of Family Medicine
Oregon Health and Science University Bayfront Medical Center
Portland, Oregon St. Petersburg, Florida
Robert L. Hatch, MD, MPH Michael Seth Smith, MD, PharmD
Professor University of Florida
Department of Community Health and Family Department of Community Health and
Medicine Family Medicine
University of Florida Gainesville, Florida
Gainesville, Florida
Charles W. Webb, DO, FAAFP
John Malaty, MD Associate Professor
Assistant Professor Director, Sports Medicine
Department of Community Health and Family Department of Family Medicine
Medicine Associate Professor
Shands Hospital at University of Florida Department of Family Medicine and Orthopedics
Gainesville, Florida Oregon Health and Science University
Portland, Oregon
Ryan C. Petering, MD
Clinical Instructor
Department of Family Medicine
Oregon Health and Science University
Portland, Oregon
Michael J. Petrizzi, MD
Clinical Professor
Department of Family Medicine
Virginia Commonwealth University School
of Medicine
Richmond, Virginia
v
preface
From the earliest conception of this book through and casts. Another update in this edition is the
the publication of this third edition, it has always inclusion of patient education handouts that can
been our intent to produce a practical user-friendly be downloaded from the online version of the
book that helps clinicians manage their patients book. These handouts will give your patients infor-
who have fractures. We have accomplished this mation about the healing process and the kinds of
through a systematic approach to each fracture rehabilitation exercises they can do to return to
that enables you to find the information you need full activity after an injury. The online book also
quickly, including what to look for, what to do in includes videos covering techniques for splinting
the acute setting, how to manage the fracture long and reducing dislocations.
term, and when to refer. The many high-quality We would like to thank the many individuals
radiographs and illustrations help clinicians prop- who helped us in the preparation of this edition.
erly identify those fractures that can be managed We thank our contributing authors for their assis-
by primary care providers and those that need to tance with individual chapters and the appendix:
be referred. The basic systematic format of the text Ryan Petering, MD (Finger Fractures and Carpal
has been retained, but information from the second Fractures), Charles Webb, MD (Metacarpal Frac-
edition has been significantly revised to include tures), John Malaty, MD (Facial and Skull Frac-
current evidence and references. We have expanded tures), Adam Prawer, MD (Radius and Ulna
the discussion in the imaging sections for each Fractures), Michael Seth Smith, MD (Metatarsal
fracture to include evidence regarding preferred Fractures), and Michael Petrizzi, MD, and
modalities for identifying fractures. Aspects of the Timothy Sanford, MD (Appendix). We thank
emergency care of fractures, including guidelines Walter Calmbach, MD, for his contribution to the
for emergent referral and greater detail regarding first two editions of the book. We also thank
methods for closed reductions for fractures and dis- Janice Gaillard, senior developmental editor, at
locations, are featured in this edition. New radio- Elsevier for her guidance and advice. And finally,
graphs and illustrations have been added to give we are grateful to the many practicing clinicians
you optimal examples of the fractures you will who have encouraged us to take this next step
encounter. in pursuit of our vision to give you the most accu-
This edition builds on the success of the second rate and practical working guide to fracture
edition and gives you an even better reference for management.
your practice. One of the most notable changes is M. Patrice Eiff
the addition of an entire section devoted to step-
Robert L. Hatch
by-step instructions on applying a variety of splints
vii
introduction
Fracture ManageMent: remark to the ED physician, “I don’t look at bone
a Personal View films too often, but even I can tell that these don’t
look quite right.”
I’ve always enjoyed teaching sports medicine and My X rays that “don’t look quite right” provide
fracture management, but I never aspired to an excellent tool to reinforce the orthopedic prin-
become an orthopedic teaching case. That was all ciple that one should always obtain two views
to change on the Mambo Run in January 1988. taken at 90-degree angles from each other when
While I was lying in the snow awaiting trans- evaluating skeletal injuries. At first glance the
port, my mind quickly began running through a X rays tend to create confusion and some head
differential diagnosis. My first thought was a femur scratching. Confusion turns to a somewhat queasy
or tibia fracture. A few torn ligaments were cer- feeling when viewers realize that they are looking
tainly a possibility. After the Ski Patrol member at the femur and tibia at 90-degree angles from
said, “Something doesn’t feel quite right,” I revised each other on the same view.
my differential to put patellar dislocation at the top One’s own joint injury or fracture can certainly
of the list. Of course, that must be it. I wanted that generate interest in orthopedics. In my case, my
to be it. knee dislocation fueled a passion to write this book
In the emergency department of the local hos- and help others manage patients with orthopedic
pital, I got the first glimpse of my knee. Admittedly injuries. There have been many advances in the
it didn’t look right, but I was unwilling to broaden management of fractures and imaging techniques
my differential. The physician on duty pulled since the first edition of this book was published in
the sheet back and said something like, “Oooh! 1998, but plain films can still tell a story. Even if
Give her some morphine and call the orthopedic my X-ray picture isn’t worth a thousand words, it
surgeon.” My concern was mounting. As I might be worth a teaching point or two.
was wheeled back from the X-ray department, I
overheard my surgeon and skiing companion M. Patrice Eiff, MD
ix
1
FRACTURE MANAGEMENT BY
PRIMARY CARE PROVIDERS
The evaluation and management of patients with survey of West Virginian family physicians revealed
acute musculoskeletal injuries is a routine part of that 42% provided fracture care.6 The majority
most primary care practices. Distinguishing a frac- of the respondents of the survey practiced in
ture from a soft tissue injury is an essential part rural areas.
of clinical decision making for these injuries. The distribution of various types of fractures
To provide physicians, nurse practitioners (NPs), managed by family physicians has been reported in
and physician assistants (PAs) with adequate train- a few studies.7-9 Two of these studies were done in
ing and continuing education in fracture care, we military family practice residency programs, and
need to know more about the scope, content, and the other was performed in a rural residency prac-
outcome of this aspect of their practices. tice in Virginia. The distribution of fractures is
presented in Table 1-1. The most common injuries
Primary Care PhysiCians encountered were fractures of the fingers, radius,
metacarpals, toes, and fibula. A report of the epi-
Determining the extent of fracture management demiology of nearly 6000 fractures seen in an
performed by primary care providers starts with a orthopedic trauma unit in Scotland during the year
query of large databases that catalogue the most 2000 found the top five fracture locations to be
common diagnoses encountered in primary care. the distal radius, metacarpal, proximal femur,
The National Ambulatory Medical Care Survey finger, and ankle.10
(NAMCS) is the most comprehensive database Family physicians vary in which fractures they
available to characterize visits to office-based phy- manage and which they refer. This is often based
sicians in many specialties.1,2 Based on the author’s on the accessibility of orthopedic specialists, prac-
(MPE) analysis of 2005 data, in a representative tical experience with fractures, and amount of frac-
national sample of more than 25,000 patient visits, ture management taught during family medicine
fractures and dislocations made up 1.2% of all residency training. In settings in which family phy-
visits and ranked 18th of the top 20 diagnoses. As sicians have considerable experience in fracture
expected, orthopedic surgeons saw most of the management, the overall rate of fracture referral to
patients with fractures (68%). Family physicians orthopedists varies from 16% to 25% (excluding
handled the majority of the remaining visits (10% fractures of the hip and face).6,8,11 Most fractures
of the total fracture visits). Visits to family physi- are referred because of the presence of at least one
cians, general internists, and general pediatricians complicated feature, such as angulation or dis-
accounted for approximately 18% of the total visits placement requiring reduction, multiple fractures,
for fracture treatment. Fracture diagnoses rank intraarticular fractures, tendon or nerve disruption,
thirteenth among children younger than 17 years or epiphyseal plate injury.
of age. Orthopedic surgeons provided 65%, family Although we have an understanding of the
physicians provided 6%, and pediatricians pro- common types of fractures seen by family physi-
vided 17% of the visits for pediatric fractures. cians, less is known about the outcomes of fractures
In a 1979 study using national, regional, and managed by family physicians. In a study of 624
individual practice data, orthopedic problems con- fractures treated by family physicians, healing
stituted approximately 10% of all visits to family times for nearly all fractures were consistent with
physicians, and fractures accounted for 6% to standard healing times reported in a primary care
14% of the orthopedic problems encountered.3 In orthopedic textbook (Table 1-2).8 In a retrospec-
studies done in the early 1980s, fracture care varied tive study, Hatch and Rosenbaum9 collected infor-
in rank from 19th to 28th in relation to other mation about the outcomes of 170 fractures
diagnoses made by family physicians.4,5 A 1995 managed by family physicians. Only four patients
1
2 FRACTURE MANAGEMENT FOR PRIMARY CARE
Table 1-1 Percentage Distribution of Fractures Seen by Family Physicians
FRACTURE EIFF AND SAULTZ8 HATCH AND ROSENBAUM9 ALCOFF AND
(N = 624)* (N = 268)* IBEN7 (N = 411)†
Finger 17 18 12
Metacarpal 16 7 5
Radius 14 10 16
Toe 9 9 1
Fibula 7 7 7
Metatarsal 6 5 4
Clavicle 5 6 7
Radius and ulna 4 6 4
Carpal 2 1 5
Ulna 2 2 3
Humerus 2 4 3
Tibia 2 4 4
Tarsal 1 1 2
*Number of fractures.
†Number of fracture visits.
had a significant decrease in range of motion, and have been found to provide care similar to one
only 10 patients had marked symptoms at the end another and physicians in regards to diagnostic,
of the follow-up period. Fractures requiring reduc- therapeutic, and preventive services in a primary
tion, intraarticular fractures, and scaphoid frac- care setting.12
tures had the worst outcomes. Complications A few studies have documented how often NPs
noted in the total group were minor and with rare encounter acute orthopedic problems in practice.
exception resolved fully during treatment. The A study of a nurse-managed health center in rural
authors concluded that the vast majority of frac- Tennessee found that minor trauma and acute mus-
tures treated by family physicians heal well and culoskeletal problems represented 8.5% of all acute
that most adverse outcomes can be avoided if conditions treated.13 The incidence of fractures
family physicians carefully select which fractures encountered was not specifically stated. Respon-
they manage. dents to a survey study of family nurse practitioners
throughout the United States reported “neurologic/
nurse PraCtitioners and musculoskeletal” problems as the second most
PhysiCian assistants common category of cases seen in their practices.14
Accidental injuries were encountered at least one
As more and more NPs and PAs join primary care to three times a month. In another national survey
teams, especially in rural communities, they will study, fractures ranked 13th out of the top 15
need skills in managing fractures. PAs and NP’s diagnoses in patients seen by 356 family nurse
Table 1-2 Healing Time of Acute Nonoperative Fractures
FRACTURE ACTUAL HEALING TIME* RECOMMENDED LENGTH OF
(WEEKS) IMMOBILIZATION† (WEEKS)
Proximal phalanx 4.1 4
Middle phalanx 3.7 4
Distal phalanx 4.4 3
Metacarpal (excluding fifth) 4.9 4
Fifth metacarpal (boxers) 5.1 4
Scaphoid 7.7 6-12
Distal radius 5.6 6
Distal radius and ulna 6.7 6
Clavicle 3.9 4-6
Fibula 5.9 7-8
Metatarsal 5.9 4-6
Toes 3.6 3-4
*Median values for time from injury to clinical healing (see Alcoff and Iben7).
†Eiff MP, Saultz JW. Fracture care by family physicians. J Am Board Fam Pract., 1993;6(2):179-181.