What is the management of an acute nondisplaced fracture of the proximal tibial metaphysis in the emergency department, specifically regarding splinting, referral to orthopedics (ortho), and pain medication prescription upon discharge?

From the Guidelines

Management of an acute nondisplaced fracture of the proximal tibial metaphysis in the emergency department should include immobilization with a long leg posterior splint, non-weight bearing instructions, and referral to orthopedics within 1-2 weeks. Pain management typically consists of acetaminophen 650-1000mg every 6 hours and an NSAID like ibuprofen 400-600mg every 6 hours, alternating between the two medications, as recommended by 1. For moderate to severe pain, a short course of opioids may be prescribed, such as oxycodone 5mg every 4-6 hours for 3-5 days, with caution and consideration of the patient's individual needs and risk factors, as noted in 1. Patients should be discharged with crutches and instructed on proper non-weight bearing ambulation techniques. Ice should be applied for 20 minutes every 2-3 hours while awake for the first 48-72 hours to reduce swelling, and elevation of the affected limb above heart level when sitting or lying down is also important to minimize swelling, as general principles of fracture management suggest. This approach provides temporary stabilization of the fracture while preventing displacement, which could lead to malunion, delayed union, or the need for surgical intervention. The proximal tibial metaphysis has good blood supply, which generally favors healing, but proper immobilization and orthopedic follow-up are essential to ensure optimal alignment and function. It's also important to consider the patient's pain intensity and use appropriate pain measurement scales, such as the numeric rating scale (NRS) or the visual analogue scale (VAS), as discussed in 1. In patients with severe dementia or non-communicative patients, observational and surrogate reports can be used for pain assessment, and tools like the Pain Assessment IN Advanced Dementia (PAINAD) or the Functional Pain Scale may be helpful, as mentioned in 1. Overall, the goal is to provide effective pain management while minimizing the risk of adverse events and promoting optimal healing and functional outcomes. Key considerations include:

• Immobilization with a long leg posterior splint
• Non-weight bearing instructions
• Referral to orthopedics within 1-2 weeks
• Pain management with acetaminophen and NSAIDs, with cautious use of opioids
• Use of crutches and proper non-weight bearing ambulation techniques
• Ice and elevation to reduce swelling
• Consideration of individual patient needs and risk factors
• Appropriate pain measurement and assessment tools.

From the Research

Management of Acute Nondisplaced Fracture of Proximal Tibial Metaphysis

• The management of proximal tibial fractures has evolved significantly in recent years, with a trend towards tailored approaches for particular fracture localizations 2.
• For nondisplaced or minimally displaced fractures with little soft-tissue injury, closed treatment can be reserved 3.
• In the emergency department, a splint and referral to ortho with a pain medication prescription on discharge may be appropriate for acute nondisplaced fracture of proximal tibial metaphysis.
• Nonoperative treatment is indicated for nondisplaced or adequately reduced fractures, while operative treatment is indicated for irreducible fractures or fractures with loss of adequate reduction 4.

Treatment Options

• Closed management often leads to varus malunion, especially when the fibula is intact, and should be reserved for nondisplaced or minimally displaced fractures with little soft-tissue injury 3.
• External fixation remains the most versatile method and is indicated for fractures with short proximal fragments and in cases of extensive soft-tissue injury that would preclude use of other surgical techniques 3.
• Intramedullary nailing can be useful for stabilizing fractures with proximal fragments longer than 5 to 6 cm, but can lead to valgus malunion in a sizable percentage of patients with this injury 3.
• Plating of the proximal tibia has become a less popular alternative due to the high incidence of infection and fixation failure, but can be effective in certain cases 3, 5.

Decision Making

• An algorithm that takes into account the severity of soft-tissue injury, the length of the fracture fragment, and the degree of fracture stability can help with decision making among current treatment techniques 3.
• The fracture pattern should be correctly identified and understood to determine the best course of treatment 5.