Wednesday, May 30, 2007
Yadier Molina broke his wrist while catching for the St. Louis Cardinals yesterday and some may be surprised that he won’t get casted for a few days. He may not even need an operation. And while I don’t understand the rules for baseball’s injury reserve list (why is he on the 15 day disabled list, when the team knows he will be out for 4-6 weeks), I do know what’s going on with fracture care.
First a few quick definitions. Broken, cracked or fractured all mean the same thing, that the integrity of the bone is no longer intact. One term is not worse than another. How many times have people thanked me that their ankle wasn’t broken, just fractured. I have to remind myself to do the definition list at the bedside as well. Fractures can be displaced or non-displaced and this tries to explain whether the bones are aligned properly. Some amount of displacement is allowed depending on which bone is broken and where in the bone the break occurs. The body can remodel bones as they heal, so displaced does not automatically equal having to “set” the bones. Setting means reducing or realigning the bones so they look and function better. The vast majorities of fractures that have to be reduced will have that procedure done under anesthetic. And sometimes, bones that appear well aligned right after the injury may move and then require reduction later on. Finally, if the skin over the fracture is lacerated or torn, this is considered an open fracture and needs work to clean out the area since the outside world has invaded the break and the risk of infection is high.
Initially in the emergency department or the doctor’s office, once the diagnosis of a fracture is made, and the decision is made that an operation is not needed, then the fracture is splinted. The splint is a bulky half cast that immobilizes the injury but also allows the routine swelling that occurs after a break. In a few days, if the patient has been following instructions, icing and elevating the injury, and the swelling is controlled, the splint is removed and a circular cast is applied. The cast gives better protection and allows the fractured bone to heal.
If a circular cast were put on immediately after the injury, then one of two things would happen. Either the area would swell or the patient would return with intense pain because the cast acts like a tourniquet and cuts off blood supply, or the swelling that was already there might subside and the cast would become loose and have to be replaced.
One occasion, the orthopedic surgeon may choose to put on a cast right away to try to hold a fracture in place and hopefully prevent the need for an operation. This would require lose follow up to make certain the tourniquet effect of swelling did not occur.
Timing is the key to the care of broken bones. As long as alignment is reasonable, the skin is not broken, the blood vessels and nerves are still working and the pain is controlled, then the opportunity exists to go a little slower in the decision making. For some fractures, the operating room is the only option, but for others, the body is pretty good at healing itself, if the docs can help it along.