Sarah Bolander, DMSc, PA-C, on Eponymous Extremity Fractures

In this podcast, Sarah Bolander, DMSc, PA-C, discusses appropriately identifying and describing common eponymous extremity fractures in a primary care setting.

Additional Resource:

Sarah Bolander, DMSc, PA-C, is an associate professor in the Physician Assistant Program at Midwestern University, and a physician assistant at Cactus Pediatric Orthopaedics in Scottsdale, Arizona. 


 

TRANSCRIPT:

Leigh Precopio:  Hello everyone, and welcome to another installment of Podcast360, your go‑to resource for medical news and clinical updates. I'm your moderator, Leigh Precopio, with Consultant360.

Accurately identifying and describing eponymous extremity fractures is an important part of any primary care provider's skill set. Yet, it is an ability that comes with time and experience. Reviewing radiological findings, terminology, and characteristics of common extremity fractures is critical, as many of these injuries are often mislabeled.

To learn more about properly identifying and describing these fractures, Consultant360 reached out to Sarah Bolander, DMSc, PA-C, who presented on this topic at the 2021 American Academy of Physician Assistants annual conference. Sarah is an associate professor in the physician assisted program at Midwestern University in Glendale, Arizona. Thank you for taking the time to speak today, Sarah. To begin, could you give us a brief overview of your session?

Sarah Bolander:  Yes, absolutely, of course. First of all, I'd like to thank Consultant360 for this opportunity to discuss this session and for AAPA to allow me to present on this topic during the recent virtual conference.

Eponymous fractures and fracture dislocations are commonly named after the individual that initially described them. This session went through not only the language of fractures, but helped to clarify the specific fracture patterns that are associated with fractures that have eponyms. We used common upper and lower extremity fractures that have specific names to them, to better work through identifying and describing fractures. The goal was overall to practice identifying describing fracture by using these eponyms as examples.

Fracture identification and description can be extremely challenging. It's a skill that needs to be developed through practice, and not everyone gets that opportunity to practice that on a regular basis. We definitely wanted to use eponyms as a way to guide that practice, but also make sure that we clarified so that we're using those terms correctly.

Leigh Precopio:  What are some common pitfalls primary care providers make when identifying and describing eponymous extremity fractures?

Sarah Bolander:  Eponymous fractures do allow for a rapid and succinct identification of very complex injuries, which can be extremely beneficial. Unfortunately, often these named injuries are mistermed. That can create some confusion. Often it can misdirect management, including the urgency of the treatment that's needed for these different injuries.

We need to avoid overall casually using these eponyms unless we're confident that they actually describe the fracture that's being presented. They can lead to being either missed or misdiagnosed. For example, a Colles fracture technically doesn't have articular involvement, whereas a dorsal type of a Barton fracture does. Although they appear very similar on imaging with some dorsal displacement, we need to know if there's articular involvement or not. That definitely can affect our treatment and potential long‑term outcomes from this type of an injury.

Leigh Precopio:  Do any specific patient characteristics, such as those at risk for osteoporosis, impact how you identify and describe fractures?

Sarah Bolander:  This is actually a great question. We know that osteoporosis weakens the bone. It definitely increases our risk for fractures, particularly in certain locations of the body. For example, the hip, the wrist, the spine. But these are considered more insufficiency fractures. They don't necessarily change how we identify or describe them other than adding that component because we need to be able to evaluate the quality of the bone. What they do is they can affect our treatment strategy based on that quality and what options we have. They can direct the care to prevent additional fractures.

To be honest, anytime there's a fracture in the bone, we do need to take the time to assess the quality of the bone. We become particularly concerned if there's something like a pathologic fracture. These fractures can be challenging to fully describe because they require additional considerations. Any underlying condition that can increase your risk for fracture needs to be worked up. This can be benign, or it might be malignant.

We need to be concerned of these potential additional features, such as concerns with the border, or additional bone destruction. There might be some abnormal periosteal reaction that we need to address. We may see some involvement into the soft tissue. We need to then further workup our history, as well. Deciding if there was pain prior to the injury. If they have any history of cancer, for example. We might be concerned about a metastatic lesion.

So, radiographs are extremely valuable to differentiate these concerning features and can further guide our workup and management and where their next step might be in referral process, as well.

Leigh Precopio:  How does identifying and describing extremity fractures differ in children and adolescents from adults?

Sarah Bolander:  Children and adolescents are unique when it comes to fractures. It's a whole other group. Children have unique fracture patterns because they have more plasticity to their bone. They have the strength of their periosteum. They have potential for remodeling, so even as they continue to heal, and develop they this potential that adults don't have.

Often, their treatment is different. When it comes to describing them, they have incomplete fractures. Such as a buckle fracture, which is also commonly called a Torus fracture. They may have a greenstick fracture or a bowing deformity. They present differently, and these are described differently.

They often don't have as significant displacement with those types of injuries. Although they can have complete fractures like adults. There are several fractures with eponyms that they can share. Then there's other variants that are specific to the age and population, particularly if it's involving their growth plate. Any patient that is still skeletally immature will have these growth plates, the physis. If a fracture involves the physis, it needs to be further described. We actually use the Salter‑Harris classification, which is another eponym. That helps us to determine the location of the fracture and the involvement of the physis. If it extends into the metaphasis or the pethasis or both.

That can help us not only with some of the termed fractures such as a Tillaux fracture, which is a Salter‑Harris three fracture we see in the distal tibia, versus a triplane fracture that's a Salter S4 fracture, where you're seeing differences on different views of where the epiphysis and the metaphasis and physis are involved in this type of a fracture.

When we get the growth plate involved in these types of injuries, there are definitely some additional components in describing them. This helps guide management, but also gives some of some potential long‑term effects to growth, as well.

Leigh Precopio:  What other knowledge gaps exist among primary care providers and orthopedic topics?

Sarah Bolander:  That's a challenging question because unfortunately, I feel that many providers don't receive a rigorous musculoskeletal training. For example, in PA school, we don't have a rotation specific to orthopedics, so unless this is an area of interest, and something you choose to specialize in, many providers may feel they lack the expertise or the comfort level for treating some of these conditions. They feel more comfortable referring out.

Another thing that comes up is with musculoskeletal imaging. Often, we rely on the radiology interpretation. We wait for that, or we're not confident with our exam. We don't take that time to clinically correlate. It's so extremely important that we make sure we not only take a look at imaging but make sure that that does match up with what we're seeing in our practice and how our patient is presenting.

Often, there are many normal variants that we may see, especially in the pediatric population. We need to make sure that that correlates with how they're presenting today. Especially when there's abnormalities in the bone, as well. Making sure is that a concern with the injury that they're presenting with today, or does that happen just to be an incidental finding, for example?

It's hard because of the topic. Although it's on eponymous fractures and the goal is to better describe these named fractures and really understand what is involved in these and how they got their name, it's more important that we know our fracture terminology and how we better describe fractures. And that we can specify location, which can be more complicated than just saying which bone, where in the bone? If there's any special terminology with that. The type, the pattern, the position, that can get complicated on if there's displacement, emulation, translation. Any potential complications, such as if it's an open fracture. If this is something we'd want to lead with. That's going to definitely change our management.

There's so much more that goes into identifying and describing a fracture. We need to be careful if we're going to label it and give it a name. It can be so helpful, but at the same time, we may be missing something that is critical in the injury and how they're presenting.

Leigh Precopio:  Thank you so much for taking the time to answer my questions today.

Sarah Bolander:  I so sincerely appreciate it. I always look forward to the opportunity to discuss fractures and definitely am grateful to Consultant360 for this opportunity. Hope that others can find opportunities to learn more about orthopedics and fractures. That there's many opportunities out there to gain that knowledge and skill if that's an area of interest.

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