Comprehensive Fracture Care in Rural Setting
Disclosures
Rural Fracture Care
THE FRACTURE SAFARI
I do not receive any
material benefit from
any medical supply
company for trauma
equipment but…
Chris Parfitt, MD, FRCS
Instead of this (Montreal!)
Romance of Rural Medicine
• Driving
I see this! (Albreda Mountain)
Romance of Rural Medicine
• Be careful out there
• Good time to talk
about fractures!
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Comprehensive Fracture Care in Rural Setting
Learning objectives
• You did not come
here to learn how to
do this
• (I am sorry!)
Digital X-rays allow easy consult
• If in doubt, always call
your friendly local
orthopaedic surgeon
•
Please don’t mention my name!
Learning objectives
• You came here to
learn or review what
to do with this patient
Variety of Opinion
• Orthopaedic surgeons
are like farmers
arguing over the best
farming methods
• THIS IS WHAT I DO
ON MY FARM
Regarding distal radial fractures
PRE-TEST
Which one is false?
1. Casting does not hold reduction
2. Locking plates can hold reduction
3. In elderly (60 plus), the outcome of these
is equal whether treated with cast or plate.
4. These fractures can be treated by a rural
family doctor
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Comprehensive Fracture Care in Rural Setting
How would you treat this #
1.
2.
3.
4.
Refer for surgery
Figure of 8 bandage
Simple sling
Airplane splint
How would you immobilize this?
1. Thumb spica cast
2. Refer for surgery
3. Below elbow cast
4. Splint
Watson’s test is:
1.
2.
3.
4.
Clinical test for shoulder instability
A clinical test for Achilles tendon tear
A good way to test the scaphoid
Sherlock Holmes’ partner’s test
Comprehensive Fracture Care
What is true of this FX
• Monteggia fracture
DL
• Called fracture
necessity
• Can be treated by
rural family physician
• Named after famous
British surgeon
Treat the Fracture
• Treat the Whole Patient
• Decision to refer
• Identify and prioritize other injuries ATLS
• Or treat the patient at
your own location
• Always check neurovascular status of the
fractured limb
• Then
• What is this injury?
• PRIZE QUESTION
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Comprehensive Fracture Care in Rural Setting
Principles of Fracture Management
Fracture Treatment
Checklist
SAFARI
1. Set (reduce) the Fracture
• Start with a straight
bone
• Alignment never
improves with followup
SET the fracture
ARREST (immobilize)
FOLLOW-UP
ACTIVATE
REHABILITATE
INVESTIGATE
I
What is acceptable angulation
• Acceptable angulation
is where you END UP
• Most fractures wander a
bit in casts
• Patients have little
tolerance for acceptable
angulation
2. Arrest (immobilize)
1. Cast
2. splint
3. Internal fixation
After immobilization
• ELEVATION AND
ICE
• ELEVATION AND
ICE
• ANALGESIA
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Comprehensive Fracture Care in Rural Setting
3. Follow-up of Fractures
• In adults and
adolescents TAX
weekly for most
• In small children TAX
every 3 to 4 days
(they heal fast)
• Follow until healing
prevents
displacement
4. Activate the limb
• Start activation of the
limb on your first
follow-up visit
• Helps prevent CRP
syndrome
5. Rehabilitate
• Healing comes from
within, therapist is
motivator but has
special techniques
that can help
• Always offer some
physio
• Be aware of third
party issues
3. Followup fractures
• Always check the Xray yourself or get a
verbal report
• Never rely on the
written report
Activation of the Limb
• Start immediate ROM of
restricted joints
• Weekly TAX sessions a
good opportunity to
monitor limb condition
and encourage ROM
and strengthening
6. Investigate
• 6. Determine the
need for investigation
of the cause of the
fracture, i.e.
osteoporosis, child
abuse, balance
disorders, etc.
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Comprehensive Fracture Care in Rural Setting
Paediatric fractures
• Fractures In growing
bones
• From birth
Paediatric Fractures Etiology
• Accidental injuries
Paediatric Fractures
• Until the growth
plates close
Paediatric fractures NAI
NAI or child abuse
fractures
Vs
• No accidental injury
(NAI)
Children's Fractures NAI
• Most commonly in
ages less than 3
• Most specific
fractures are
• 1. Metaphysial corner
or bucket handle
fractures
• (almost diagnostic for
NAI)
Miss these at the
patient’s and your
peril!
Paediatric fractures NAI
• Corner fracture
(diagrammatic)
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Comprehensive Fracture Care in Rural Setting
Paediatric fractures: NAI
Paediatric fractures NAI
Typical fractures
• Typical fractures:
2. Rib fractures
• Skull
• Sternum
• Scapula
TAKE HOME MESSAGE NAI
Have high index of
suspicion for non
accidental injuries
Get social worker
involved early
Treat parents with
dignity
Paediatric fractures’
fractures’ classification
• Salter Harris
classification
• Dr Salter from
Toronto here
• Dr Robert Harris also
from Toronto
Salter mnemonic
• Salter Harris 1
• 5%
Salter mnemonic
Type 2
• 75%
• S
• A
• Straight through
• Away from growth
plate
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Comprehensive Fracture Care in Rural Setting
Salter mnemonic
Salter mnemonic
• Salter Harris Type 3
• 10%
• Salter Harris Type 4
• 10%
• L
• TE
• Fracture below the
physis
• Through everything
Salter mnemonic
•
•
•
•
Type 5
Rare
R
Rammed (crushed)
Premature physial closure
• Distal radius fractures
• Less common than
lower limb
• Angular deformity
better tolerated in
upper limb
Premature physial closure PPC
• Complication of
growth plate injuries
• Common in tibia and
femur (even in grade
1 and 2 injuries)
Premature physial closure
• Reduction restores
alignment, but does
NOT change the
incidence of
premature physial
closure
• Journal Ped.
Orthopaedics 2013
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Comprehensive Fracture Care in Rural Setting
TAKE HOME MESSAGE
METACARPAL
FRACTURES
• Treat as any other
fracture (SAFARI)
• Always mention
premature physial
closure to parents
• Follow-up for 6
months at least post
fracture
Metacarpal Fractures:
Assessment
Metacarpal Fractures X-rays
• True AP
• Swelling
• Only really important
observation is
assessment of
rotation of fingers
Metacarpal Fractures: X-rays
• True lateral
• Oblique view
increases apparent
saggital deformity
because the 5th
metacarpal is a
slightly curved bone
Acceptable Angulation
of Metacarpal Fractures
• Up to 40 degrees metacarpal neck 5
• More proximal fracture creates more
deformity, accept less deformity
• Metacarpals 2 and 3 accept little, 5 to 10
degrees of deformity
• Rotational deformity not acceptable
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Comprehensive Fracture Care in Rural Setting
Metacarpal # Reduction
• Easy to straighten the
bone with Marcaine
block around fracture
• Use Marcaine with
epi and a long 25
needle
Pedestal Cast
• Holds wrist in
GENTLE extension
with moulding under
metacarpal head
• Effective to hold
reduced and nondisplaced fractures
Metacarpal Fractures: Rx
• Frontal view of cast
with pressure point
under fractured
metacarpal head
Metacarpal # Immobilization
• Ulnar gutter is
traditional
• Gives comfort to the
patient and comfort to
the doctor
• Not good for anything
else
Metacarpal Fractures: Rx
• Because the wrist
wants to fall into
relative flexion, there
is always pressure on
the metacarpal head
Example metacarpal fracture
• Lateral X-ray
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Example Case Metacarpal fracture
Metacarpal Fractures: Followup
• Reduced
• Now just follow with
weekly X-rays for 4 to
5 weeks and take the
cast off and start
range of motion of the
MCP joint
• Pedestal cast
Reasons for Referral
• Open injuries
• Rotational deformity
• Multiple unstable
fractures
• Patient demand
Scaphoid Fractures: Dx
• History: dorsiflexion
injury
• Snuffbox tenderness
Scaphoid Fractures
• Need to diagnosis
before you can
manage it
Watson’s test
• Very sensitive test for
scaphoid fractures
and scapholunate
separations
• Find the tuberosity of
the scaphoid
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Comprehensive Fracture Care in Rural Setting
Watson’s test
• Put your thumb on the
tubersity as you hold
the wrist
Watson’s test
• Ulnar deviate the
wrist
• This extends the
scaphoid
Watson’s test
• Radial deviate the
wrist
• This flexes the
scaphoid
Scaphoid # Xrays
• Wrist with scaphoid
view
• Negative X-ray
• Immobilize and
follow-up
OUCH!
Scaphoid # negative X-rays
• Immobilize and TAX
in about 2 weeks
• If still sore and
negative x-ray arrange a bone scan
• CT and MRI have
lower sensitivity rate
Scaphoid # immobilization
• The old
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Comprehensive Fracture Care in Rural Setting
Casting scaphoid fracture
• The new (Schramm
2007)
• The thumb can be left
free at the MCP joint
• Much more functional
cast
• Much happier patient
Scaphoid Fractures: Rx
• X-rays are not
conclusive to prove
healing
• Once you are fairly
sure it is healed, put
in a splint and
arrange a CT scan
Scaphoid Surgery
• However, most larger
reviews and
metanalyses show no
benefit of surgery for
undisplaced fractures
of the scaphoid
• Always some
complications with
surgery
Scaphoid # follow-up
• Review every 4
weeks
• Expect 10 to 12
weeks for healing!
Scaphoid Fractures: Surgery
• Some subspecialty
papers point to the
advantage of fixing all
scaphoid fractures
• Same healing time,
but less time in a cast
and less time off work
Scaphoid Fractures
• Indications for referral
• 1. Displaced
fractures more than
1mm
• 2. Proximal fractures
• (60 to 70 % healing in
a cast)
• 3. Patient and
Surgeon preference
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Scaphoid Fractures: Surgery
Proximal displaced
fracture
Refer this one
Prize question
Prize Question
• What is wrong here?
Distal Radial Fractures
• What is the diagnosis
• foosh
Normal Anatomy distal radius
Anterior Posterior view
Normal Anatomy distal radius
• Lateral view
• 11 degrees volar
angulation
Radial length
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Comprehensive Fracture Care in Rural Setting
Distal Radial Fractures
• Usual deformity is
dorsal angulation and
radial shortening and
radial fall-off
• Talking about Dorsal
angulated fractures
Goal of Reduction
• Younger adults should be restored to as
anatomical as possible
• Older adults should be reduced to at least
neutral on the lateral film and try to
minimize radial length loss
Distal Radial # Reduction
• Anesthesia can be
achieved with a
hematoma block
• Or conscious
sedation
Goal of Reduction
Poor outcome related to
1. Intra- articular step
deformity > 2mm
2. > 11 degrees of
dorsal angulation
3. >3 to 4 mm of radial
shortening
Distal Radial Fracture
• Arora 2009
• Anatomic plating gives no better function
and patient satisfaction than cast
treatment in older patients (over 70 years
of age)
• Regardless of the X-ray!
Distal Radial Fractures:
Reduction
• Reduction is achieved
by milking the
fragments with
traction on the thumb
and radial fingers
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Comprehensive Fracture Care in Rural Setting
Distal Radial Fractures:
Reduction
• Patient laying on
stretcher
• Have plaster or
fiberglass with warm
water ready to go
Distal Radial Fx: Casting
•
•
•
•
Cast is not too tight
Just 3 point molding
Below elbow
Send home with
analgesics, elevation
and ice
Example Distal Radial Fracture
• Initial angulation
Distal Radial # Immobilization
• Start below elbow
• Pad above elbow
• Mold as the cast
hardens
• CASTING IS SAFE
AND BETTER THAN
SPLINT
Distal Radial Fx: Casting
• Always leave the
fingers free at the
MCP joints
• Encourage ROM
• Elevation always
• Pain control
Example distal radial fracture
• Hematoma block and
casting
• Invisible composite
casting
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Comprehensive Fracture Care in Rural Setting
Example distal radial fracture
• Splint, refer from ER
Example Distal Radial Fracture
Local anaesthesia
• Molded cast
Goal of Severely displaced
fractures
• By improving the
position of the
fracture, you take the
neurovascular
structures out of risk
and reduce the need
for urgent surgery
Surgery Distal radial fractures
• Indications
• 1. Unacceptable position for age and
activity level of patient
• 2. Smith’s fracture
Distal Radial Fx: Follow-up
• TAX weekly
• Any fall off that is
significant for the age
should be referred
• Cast removal at 5
weeks and start
physio
Smith’s Fracture
• This fracture always
needs operative
fixation
• Volar angulation!
• ALWAYS REFER EARLY ENOUGH FOR
SURGERY (2 WEEKS OR LESS)
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Surgery distal radius
• Locking plate
• Screws thread into
the plate
• Holds the fracture at
the set angle
Prize Question
• What tendon is most
prone to rupture as a
complication of distal
radial fractures
Forearm # Acceptable angles
Age <6 ---10 degrees
Age 6 to 10--15 degrees
Age 10 to 12—10
degrees
Rotation 30 degrees
END UP HERE
Adult - anatomic
Surgery Distal Radial #
• Locking plate gives
early stability
• American surgeons
fix all of these
fractures
• Complication rate
20% in most studies
Forearm # Assessment
• This is the fracture
highly associated with
COMPARTMENT
SYNDROME
• Think of this in your
assessment
• Let pain be your
guide
Forearm # Reduction
• Conscious sedation
• Reduce with thumb
pointing towards the
apex of the fracture
• ie. Pronate with volar
apex, supinate with
dorsal apex
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Comprehensive Fracture Care in Rural Setting
Forearm # immobilization
• Long arm cast always
• 3 point molding
• ELEVATION AND
ICE
Forearm # follow-up
• Forearm (diaphysial)
fractures heal slower
than metaphysial
fractures
• Continue casting, first
long arm then short
arm until solidly
healed 8 weeks
minimum
Forearm # Internal Fixation
• For paediatric
fractures
• Intra-medullary wiring
Forearm# Follow-up
• X-ray weekly or more
frequent in younger
children
• Don’t wait for the
report to get to your
desk
Forearm # internal fixation
• Any displaced adult
fracture
• Proximal fractures in
children >6 years old
• Distal fractures when
less than 2 years of
growth left
Forearm # Internal Fixation
• For adults
• Compression plate
fixation
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Comprehensive Fracture Care in Rural Setting
Forearm fracture dislocatons
• Galleazi fracture
dislocation
• Called fracture of
necessity (needs
surgery)
• Refer this one
Monteggia fracture DL
• In X-ray of elbow the
radius always lines up
with the capitellum
Galleazi Fracture DL
• Treated with ORIF of
radius
Monteggia Fracture DL
• Radius always lines
up with the capitellum
• REGARDLESS OF XRAY VIEW
Monteggia Fracture DL
• Fracture ulna with
dislocation of radial
head
Monteggia Fracture DL
• Needs open reduction
internal fixation in
adults
• Closed reduction in
children
• Refer all
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Paediatric Elbow #
Elbow Fat pads
• Radial head always
Lines up with the
Capitellum
• Visualization of the
_____? pad can be
normal
Anterior humeral line
Passes through
Middle third of
capitellum
• Visualization of the
______? pad is
always pathological
Paediatric Elbow Fractures
• These fractures are
very unforgiving
• Recognize all
• Refer all
• Except the
undisplaced supracondylar fracture
Type 3 Supra-condylar #
• Brachial artery may
be damaged or
blocked by the distal
humeral fracture
• Urgent referral
• Reducing in flexion
may bring back pulse
SupraSupra-condylar # Immobilization
• Cast or splint elbow at
90 degrees
• X-ray every 5 days or
so
• Cast on 3 to 4 weeks
Type3 supra-condylar #
• Urgent reduction and
fixation
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Comprehensive Fracture Care in Rural Setting
T condylar elbow fracture
• Complicated but not
compound
Humeral shaft Fractures
• Torsional force
causes oblique
fracture
• Direct blow causes
transverse fracture
Humeral Shaft # Immobilization
• A sugar tong splint
can be used
immediately
T condylar fracture
• ORIF with olecranon
osteotomy
Humeral # assessment
• Neurovascular Check
• Always check the
radial nerve!
• No wrist, finger or
thumb extension
Humeral shaft # Followup
• X-ray every 2 weeks
• Average 8 to 10 week
healing time
• Definitive care is best
with the Sarmiento
humeral fracture
brace
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Comprehensive Fracture Care in Rural Setting
Humeral Shaft # Surgery
From a rural point of
view refer if the
fracture doesn’t line
up reasonably well in
the Sarmiento splint
(30 degrees or no bone
opposition)
INDICATIONS
1. open fractures
• 2. upper limb injuries
secondary
• 3. bilateral radial
nerve palsy
• etc
Humeral shaft # surgery
• Plate fixation is the
standard for fixing
these fractures
• IM nailing only for
pathological fractures
Clavicle # Immobilization
• Traditional figure of 8
• Like many of our
traditional practices
this has no proven
benefit . Let the
patient use what is
most comfortable eg.
sling
Humeral shaft # surgery
• This one treated in a
Sarmiento splint for 3
months
• Smoker
• No callous
Clavicle Fractures
• Most not severely
displaced
• Conservative RX
appropriate
• 90% treated
conservatively
Clavicle Fracture Follow-up
• X-ray every 2 weeks
• Don’t expect healing
for at least 8weeks
• Refer for delayed and
non unions
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Clavicle Fractures
• Multicentre Canadian
study has changed
the management of
some of these
fractures
• McKee et al 2007
Clavicle Fractures
• More recent review of
clavicle fractures
• Operative treatment
no benefit over non
operative treatment
• Cochrane review
2013
Clavicle fractures ? surgery
• Cochrane 2013
• Limited evidence for
RCT’s to show
difference between
ORIF and
conservative care
• Younger, healthier
increased
displacement refer
Clavicle Fractures
• Indications for surgery
in younger active
patients
• >2cm of shortening
• Fracture ends apart
Clavicle Fractures
• McKee et al 2012
• ORIF can shorten
disability time and
reduce the incidence
of symptomatic non
union but little
evidence to show that
long term function
improved with ORIF
Surgery Treatment Clavicle #
• Impending open
fracture
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Surgery clavicle # prize question
• What are these
nerves
Clavicle fracture
• Yes!
Clavicle Fracture
• Will this one heal?
Proximal Humeral Fractures
• Usually osteoporosis
• Majority (80%) are not
significantly displaced
Proximal Humeral Fractures:
Assessment
AP X-ray
Proximal humeral# X-rays
• Another AP Xray
What do you expect this
is?
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Proximal Humeral X-rays
• Axillary view
• X-ray techs can be
difficult to convince
but will comply if
instruction understood
Proximal Humeral Fractures:
Displacement Criteria
• > 45 degrees of
angulation
• Displacement greater
than 1 cm of parts
(head, GT,LT and
shaft)
• Legal liability to treat
without this view
Proximal Humeral Fractures: CT
• 3 dimensional CT
• Takes away the
guesswork
Proximal Humerus Surgery
• Unstable 4 part
fracture
Proximal Humeral
Fractures: Rx
• Undisplaced (80%)
need shoulder
immobilizer
• Weekly X-ray
• NO PHYSIO UNTIL
SIGNS OF HEALING
on X-ray
• Usually 4 to 5 weeks
Proximal Humerus Surgery
• Many different locking
plates available
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Proximal humeral # surgery
• What do you do here
Proximal Humeral surgery
• Your reduce it and
now you have this
• Look before you leap
• 20% of dislocations
with greater tuberosity
fractures have
undisplaced surgical
neck fractures
Proximal Humeral Surgery
Hip Fractures
• Hemi-arthroplasty
• Inter-trochanteric hip
fracture
• You diagnosis this
and send it to the
surgeon
Hip fractures
• The surgeon fixes the
fracture and sends
the patient back
ASAP
• This is a short gamma
nail
Subcapital Fracture Hip
• These fractures are
the most important
ones for you because
the undisplaced ones
are , like a scaphoid
fracture, difficult to
diagnose
• Medico-legal issues
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Comprehensive Fracture Care in Rural Setting
Subcapital Fracture Hip
• Injury, followed by hip
pain and difficulty
bearing weight is a
fracture until proven
otherwise
• MRI best, CT second
best, bone scan not
great
• Keep patient non wt
bearing
Displaced Subcapital Hip #
• In patients under the
age of 55 or so this
should be pinned with
the hope to save the
hip. Risk of
avascular necrosis
• THIS IS THE ONLY
EMERGENCY HIP
FRACTURE
Hip Fractures Followup
• This is your job in a
rural community
• X-ray every 4 weeks
• The surgeon did the
RI
• You do the FARI
Sub capital fracture hip
• Undisplaced fractures
can be
percutaneously
pinned a 20 minute
operation
Displaced Subcapital # hip
• Arthroplasty for older
people
Hip Fracture Weight Bearing
Internally fixed fractures are
very variable, most with
good fixation can walk
weight of leg
Arthroplasty can weight
bear early just like a total
hip
Always ask surgeon!
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Hip # Anticoagulation
• Most health care
organizations
recommend 28 days
average for chemical
anticoagulation
Femoral Shaft Fractures
• When the only tool
you have is a
hammer, then every
problem starts to look
like a nail
Paediatric Femur Fractures
• Up to age 5 a spica
cast is used
Hip # Investigation
• Over 80 % of older
hip fracture patients in
a Seattle study had
deficiency of VIT D
and Calcium
• You may need to do
densitometry
Femoral shaft fracture
• This is the standard of
care in the older child
and the adult patient
Paediatric femoral fractures
• Middle age group use
intramedullary wires
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Patellar Fracture
Undisplaced fractures
Patellar Fractures
• Displaced fractures
• Refer for surgery
Tibial Shaft Fractures
• Acceptable angulation
in both adults and
children
• Rotary or angular
deformity < 5 degrees
• < I cm of shortening
• 10 degrees anterior
angulation in children
Patellar Fractures Undisplaced
Reduction not needed
Immobilization –
cylinder cast
Follow-up – weekly
Cast off and physio at 5
to 6 weeks
Patella Fractures
• ORIF patellar fracture
Tibial Shaft Paediatric
• Most treated in long
leg casts
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Tibial Shaft# follow-up
• Weekly X-ray
• encourage non weight
bearing
• Patellar tendon
bearing cast as soon
as some healing on
X-ray
Ankle Fractures
• Need an X-ray to
make diagnosis
• Ottawa’s rules help
Ottawa to save
money
• Lawyers’ rules are
different
Ankle Fractures: Undisplaced
• Mostly lateral
malleolus fractures
• Usually quite stable
Tibial shaft # adult displaced
• Most of these are
nailed
Ankle fracture assessment
• Routine history
• Physical should look
for pulses as
chronically ischemic
feet are a
contraindication for
surgery
• Always examine for
medial and lateral
tenderness
Ankle fracture undisplaced
• Lateral view helps
decide whether
operative or not
• Less than 3 to 4mm
displacement on the
lateral view
acceptable for cast or
roboboot
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Ankle Fracture immobilization
• Roboboot is much
better than a cast
• You can order for
about 125 $. Weight
bearing controversial
Prize slide
• What is the diagnosis
• Where is the patient
tender
• What is the treatment
Ankle Fractures: Displaced
• Almost all of these
displaced fractures
need to be reduced
and fixed
Ankle Fracture followup
• X-ray weekly for 4 to
5 weeks
• Watch for talar shift
• Or fibular
displacement
Talar Shift: Rx
• Tell the orthopod that
this patient needs a
syndesmosis screw
• Orthopods generally
don’t like being told
what to do so you
now really have
his/her attention
Displaced Ankle fractures
• Surgical reduction
leaves 95% good
results
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Ankle Fracture closed RX?
• Does this need open
reduction?
Ankle Fracture Closed RX?
• Emergency doctor
reduced under
conscious sedation
• Healing anatomically
in cast
• Don’t underestimate
your skills
Ankle Fracture dislocation
• What to do?
Ankle Fractures:
Negative X-rays
Negative ankle X-rays
with swelling and pain
after an injury
SHOULD NOT BE
REASSURING
Fracture dislocation
• Always reduce this
Ankle Fractures: Negative Xrays
• Always examine the
foot with an ankle
sprain
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Comprehensive Fracture Care in Rural Setting
Ankle Fractures: Negative Xrays
• Always examine
Achilles tendon
Lateral Process Fracture of the
Talus
• Snowboarder’s
fracture
• Easily missed
• Prognosis is not great
• Particularly with any
displacement
Foot Fractures
• Calcaneal Fractures
• Complex decisions if
displaced
• Treat undisplaced
with NWB and
monthly x rays
Ankle fracture negative x rays
• Ankle X-ray can show
a lateral process talar
fracture
Foot Fractures
• The foot is famous for hiding midtarsal and
tarsal fractures on X-rays
• Have a high clinical suspicion and a very
low threshold to order a CT scan and refer
the patient
Foot fractures Lisfrancs
• Even minimal
displacement of the
midtarsal joints can
give permanent
disability
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Comprehensive Fracture Care in Rural Setting
Foot fractures
Base of 5th metatarsal fracture
• Metatarsal fractures
• Common
• Treat with cast or
roboboot if well
aligned.
• Refer if significant
misalignment
• Fix only those with
marked displacement
• Roboboot and FU
Distal Radial Fractures
POST TEST
A figure of 8 is no better than a
sling
• 1. casting always loses some reduction
• 2. plating holds reduction
• 3. recent studies demonstrate equal
outcome in patients age 60 treated with
casting or plating
• 4. rural family doctors can treat displaced
distal radial fractures
Scaphoid casts are passe
• Regular cast protects
as well as traditional
cast
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Comprehensive Fracture Care in Rural Setting
Watson’s Test?
• Elementary my dear Watson
Remember this guy!
• Don’t call him after
things have gone
wrong!
• If you do, instead of
calling a god, you will
be calling…
This Guy
• Godzilla
•
Thank you for coming on the
Fracture Safari
• Oops
• RIFARI
And, please, please don’t mention my name!
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