The evaluation and management of patients with acute musculoskeletal injuries is a routine part of most primary care practices. Distinguishing a fracture from a soft tissue injury is an essential part of clinical decision making for these injuries. To provide physicians, nurse practitioners (NPs), and physician assistants (PAs) with adequate training and continuing education in fracture care, we need to know more about the scope, content, and outcome of this aspect of their practices.
Primary Care Physicians
Determining the extent of fracture management performed by primary care providers starts with a query of large databases that catalogue the most common diagnoses encountered in primary care. The National Ambulatory Medical Care Survey (NAMCS) is the most comprehensive database available to characterize visits to office-based physicians in many specialties. Based on the author’s (MPE) analysis of 2005 data, in a representative national sample of more than 25,000 patient visits, fractures and dislocations made up 1.2% of all visits and ranked 18th of the top 20 diagnoses. As expected, orthopedic surgeons saw most of the patients with fractures (68%). Family physicians handled the majority of the remaining visits (10% of the total fracture visits). Visits to family physicians, general internists, and general pediatricians accounted for approximately 18% of the total visits for fracture treatment. Fracture diagnoses rank thirteenth among children younger than 17 years of age. Orthopedic surgeons provided 65%, family physicians provided 6%, and pediatricians provided 17% of the visits for pediatric fractures.
In studies done in the early 1980s, fracture care varied in rank from 19th to 28th in relation to other diagnoses made by family physicians. A 1995 survey of West Virginian family physicians revealed that 42% provided fracture care. The majority of the respondents of the survey practiced in rural areas. More recently, in a study of the scope of practice of over 2700 US family physicians who took the recertification examination in 2014, 48% reported that they manage “simple fractures.”
The distribution of various types of fractures managed by family physicians has been reported in a few studies. Two of these studies were done in military family practice residency programs, and the other was performed in a rural residency practice in Virginia. The distribution of fractures is presented in Table 1-1 . The most common injuries encountered were fractures of the fingers, radius, metacarpals, toes, and fibula. A report of the epidemiology of nearly 6000 fractures seen in an orthopedic trauma unit in Scotland during the year 2000 found the top five fracture locations to be the distal radius, metacarpal, proximal femur, finger, and ankle.
| fracture | eiff and saultz ( n = 624) * | hatch and rosenbaum ( n = 268) * | alcoff and iben ( 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 |
Family physicians vary in which fractures they manage and which they refer. This is often based on the accessibility of orthopedic specialists, practical experience with fractures, and amount of fracture management taught during family medicine residency training. In settings in which family physicians have considerable experience in fracture management, the overall rate of fracture referral to orthopedists varies from 16% to 25% (excluding fractures of the hip and face). Most fractures are referred because of the presence of at least one complicated feature, such as angulation or displacement requiring reduction, multiple fractures, intraarticular fractures, tendon or nerve disruption, or epiphyseal plate injury.
Although we have an understanding of the common types of fractures seen by family physicians, less is known about the outcomes of fractures managed by family physicians. In a study of 624 fractures treated by family physicians, healing times for nearly all fractures were consistent with standard healing times reported in a primary care orthopedic textbook ( Table 1-2 ). In a retrospective study, Hatch and Rosenbaum collected information about the outcomes of 170 fractures managed by family physicians. Only four patients had a significant decrease in range of motion, and only 10 patients had marked symptoms at the end of the follow-up period. Fractures requiring reduction, intraarticular fractures, and scaphoid fractures had the worst outcomes. Complications noted in the total group were minor and with rare exception resolved fully during treatment. The authors concluded that the vast majority of fractures treated by family physicians heal well and that most adverse outcomes can be avoided if family physicians carefully select which fractures they manage.
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