Introduction

Closed treatment has been the standard of care for all fractures until the 20th century. It remains the most widely used method of fracture management and in one recent review of 7,863 cases, 67% of all fractures were managed nonoperatively. This chapter will provide an overview of reduction techniques, indications for nonoperative fracture management, and outline principles of splint and cast application (▶Video 3.1– ▶Video 3.3).

I. Specific Reduction Techniques and Principles of Casting and Splinting

1. 
   

   Nondisplaced fractures

   
   
   
   
   1. 
      

      Almost all nondisplaced fractures can be treated nonoperatively with the exception of the femur and some unusual conditions.

      
      
   2. 
      

      The methods of immobilization include: slings, splints, casts, traction, or simply avoiding weight-bearing through the limb.

      
      
   3. 
      

      Immobilization will allow secondary bone healing to take place and function to return by 6 weeks to 3 months depending on the bone.

   
   
2. 
   

   Displaced fractures

   
   
   
   
   1. 
      

      Trauma strong enough to cause a fracture will cause surrounding soft tissue injury including periosteal disruption.

      
      
   2. 
      

      Bones are attached to muscles which contract, shorten, angulate, and rotate fracture fragments.

      
      
      
      
      1. 
         

         The fracture will often heal in the displaced position but the deformities that result may leave the limb or patient compromised and potential loss of function.

         
         
      2. 
         

         Most displaced fractures should be reduced to minimize deformity and soft tissue complications, including those that ultimately require operative fixation.

         
         
      3. 
         

         Splints provide initial stabilization of displaced fractures. They should allow for swelling and all bony prominences should be adequately padded.

   
   
3. 
   

   Indirect or closed reduction of fractures

   
   
   
   
   1. 
      

      Adequate analgesia and muscle relaxation are critical for success.

      
      
      
      
      1. 
         

         Hematoma block—aspirate hematoma and place 10 cm³ of lidocaine at fracture site.

         
         
         
         
         • 
           

           i. May be less reliable than other methods.

           
           
         • 
           

           ii. Fast and easy.

         
         
      2. 
         

         Intravenous sedation:

         
         
         
         
         • 
           

           i. Versed (0.5–1 mg q 3 minutes up to 5 mg).

           
           
         • 
           

           ii. Morphine (0.1 mg/kg).

           
           
         • 
           

           iii. Demerol (1–2 mg/kg up to 150 mg).

           
           
         • 
           

           iv. Beware of pulmonary complications with deep conscious sedation—consider anesthesia service assistance if there is concern.

           
           
         • 
           

           v. Physician should be credentialed for “conscious sedation.”

           
           
         • 
           

           vi. Pulse oximeter and careful monitoring are recommended.

         
         
      3. 
         

         Bier block—It results in superior pain relief, greater relaxation, and less premedication is needed.

         
         
         
         
         • 
           

           i. Double tourniquet is inflated on proximal arm and venous system is filled with local.

           
           
         • 
           

           ii. Lidocaine is preferred for fast onset.

           
           
         • 
           

           iii. Volume = 40 cm³.

           
           
         • 
           

           iv. Adults: 2–3 mg/kg, children: 1.5 mg/kg.

           
           
         • 
           

           v. If tourniquet is deflated after < 40 minutes then deflate for 3 seconds and reinflate for 3 minutes—repeat twice.

           
           
         • 
           

           vi. Watch closely for cardiac and neurologic side effects, especially in the elderly patients.

      
      
   2. 
      

      Reduction is accomplished by some form of traction and force directed against the deformity to correct the length, alignment, and rotation of the bone and it may be specific for fracture location and pattern.

      
      
      
      
      1. 
         

         Reduction may require reversal of mechanism of injury, especially in children with intact periosteum.

         
         
      2. 
         

         When the bone breaks because of bending, the soft tissues disrupt on the convex side and remain intact on the concave side.

         
         
      3. 
         

         Longitudinal traction may not allow the fragments to be disimpacted and brought out to length if there is an intact soft-tissue hinge (typically seen in children who have strong periosteum that is intact on one side).

         
         
      4. 
         

         Reproduction of the mechanism of fracture to hook on the ends of the fracture angulation beyond 90 degree is usually required.

      
      
   3. 
      

      Immobilization:

      
      
      
      
      1. 
         

         Fractures must be immobilized to include the joint above and below.

         
         
      2. 
         

         Maintain the position of the bone fragments to the point of healing.

         
         
      3. 
         

         Use splints initially to accommodate for potential swelling.

         
         
      4. 
         

         Three-point contact (mold) is necessary to maintain closed reduction.

         
         
      5. 
         

         Cast must be molded to resist deforming forces.

      
      
   4. 
      

      Cast padding:

      
      
      
      
      1. 
         

         Roll the padding distal to proximal.

         
         
      2. 
         

         Use 50% overlap.

         
         
      3. 
         

         Four layers minimum.

         
         
      4. 
         

         At bony prominences, use extra padding: fibular head, malleoli, patella, and olecranon.

      
      
   5. 
      

      Plaster versus fiberglass:

      
      
      
      
      1. 
         

         Plaster is better for molding, use cold water to maximize molding time.

         
         
      2. 
         

         Fiberglass is more difficult to mold but is more durable and 2 to 3 times stronger. It is also more resistant to breakdown.

         
         
      3. 
         

         Width of roll: 6 inch for thigh; 3 to 4 inch for lower leg; 3 to 4 inch for upper arm; and 2 to 3 inch for forearm.

II. Nonoperative Treatment of Displaced Fractures of the Upper and Lower Extremity

1. 
   

   Nonoperative treatment with immobilization or closed reduction is suitable for many displaced fractures such as clavicle, scapula, proximal humerus, humeral shaft, ulna, distal radius, vertebral fractures, pelvis, tibia, and ankle fractures.

   
   
2. 
   

   Patients who are not amenable to operative treatment due to medical comorbidities are candidates for nonoperative treatment.

   
   
3. 
   

   Clavicle fractures

   
   
   
   
   1. 
      

      Non or minimally displaced clavicle fractures:

      
      
      
      
      1. 
         

         These fractures heal well with a sling, physical therapy, and range of motion (ROM) exercises.

         
         
      2. 
         

         These return to normal function in 6 to 10 weeks or sooner in children and adolescents.

      
      
   2. 
      

      Midshaft clavicle fractures with > 100% displacement or shortened > 2 cm:

      
      
      
      
      1. 
         

         Nonunion rate up to 15% with nonoperative treatment.

         
         
      2. 
         

         These may heal with a symptomatic malunion.

   
   
4. 
   

   Scapula fractures

   
   
   
   
   1. 
      

      Nonoperative management is indicated for the vast majority of extra-articular scapula fractures.

      
      
   2. 
      

      Treatment consists of sling immobilization with early motion as tolerated and physical therapy as needed.

      
      
   3. 
      

      Consideration for operative fixation should be made in cases involving glenohumeral instability, displaced glenoid fractures, and significant medial displacement of the lateral border.

   
   
5. 
   

   Proximal humerus fractures

   
   
   
   
   1. 
      

      Nonoperative management is often recommended for minimally displaced fractures in all patients.

      
      
   2. 
      

      Some studies have reported little or no benefit of operative fixation for 3- and 4-part proximal humerus fractures in elderly low-demand patients.

      
      
   3. 
      

      Conservative treatment involves initial sling application with a progressive physical therapy regimen at 1 to 2 weeks post injury as pain subsides.

      
      
   4. 
      

      A thorough discussion of the indications for operative management of proximal humerus fractures can be found in Chapter 21, Proximal Humerus Fractures.

   
   
6. 
   

   Humeral diaphysis

   
   
   
   
   1. 
      

      The treatment of displaced humeral shaft fractures has been traditionally nonoperative with low nonunion rates and good outcomes.

      
      
   2. 
      

      A modern trend of operative fixation has been generating substantial interest.

      
      
      
      
      1. 
         

         Potential indications for surgical management are polytrauma, open fractures, vascular injury, inability to tolerate splinting, body habitus, and pathologic fractures.

      
      
   3. 
      

      Nonoperative management:

      
      
      
      
      1. 
         

         Initial treatment with coaptation splint (laterally above shoulder, around elbow, and along the medial arm; pad armpit well).

         
         
      2. 
         

         Conversion to functional bracing within 1 to 2 weeks.

         
         
      3. 
         

         Immobilization with a brace should be employed for 6 to 12 weeks with confirmation of fracture healing radiographically.

         
         
      4. 
         

         Elbow mobilization should begin shortly after the brace has been fitted.

         
         
      5. 
         

         Humerus easily tolerates coronal and sagittal malalignment and 3 cm of shortening. Cosmetic deformities have been noted with 30 degrees of coronal angulation and 20 degrees of sagittal deformity.

         
         
      6. 
         

         Dr. Sarmiento’s series of 620 patients treated with functional bracing for humeral shaft fractures had the following results:

         
         
         
         
         • 
           

           i. Six percent nonunion in open fractures and < 2% nonunion in closed fractures.

           
           
         • 
           

           ii. Most patients healed with < 16 degrees of anterior and varus angulation and achieved good to excellent function.

   
   
7. 
   

   Forearm

   
   
   
   
   1. 
      

      Isolated ulna fractures can be treated with immobilization if there is acceptable alignment (less than 50% translation and less than 15 degrees angulation).

      
      
      
      
      1. 
         

         Some authors recommend initial immobilization of both the wrist and elbow, while others feel the elbow can be left free.

         
         
      2. 
         

         Consider transition to ulna fracture bracing at 1 to 2 weeks post injury.

      
      
   2. 
      

      Most isolated radial shaft and both bone forearm fractures benefit from operative fixation in adults as it is difficult to maintain reduction with cast immobilization.

      
      
   3. 
      

      Nonoperative treatment in adults may lead to loss of pronation and supination.

      
      
   4. 
      

      Nonoperative treatment is the standard of care in children if alignment can be maintained in a cast (see Chapter 12, Principles of Pediatric Fracture Management, for specific guidelines).

   
   
8. 
   

   Distal radius

   
   
   
   
   1. 
      

      Many displaced distal radius fractures can be treated with closed reduction and immobilization in a cast or splint.

      
      
   2. 
      

      Traction followed by reduction in flexion and ulnar deviation is usually required to reduce a Colles fracture (two-part extra-articular fracture; Chapter 28, Distal Radius and Galeazzi Fractures, ▶ Fig. 28.4 ).

      
      
   3. 
      

      Immobilize in a splint with molding on the dorsum of the distal radius with slight flexion and ulnar deviation.

      
      
   4. 
      

      Assuming acceptable reduction is obtained, the injury should be closely monitored for maintenance of reduction.

      
      
   5. 
      

      Indications for surgical management of distal radius fractures are discussed in detail in Chapter 28, Distal Radius and Galeazzi Fractures.

      
      
   6. 
      

      Operative treatment, compared to nonoperative treatment, of displaced distal radius fractures in elderly patients has shown better radiographic results but no improvement in functional outcome.

   
   
9. 
   

   Pelvis

   
   
   
   
   1. 
      

      The majority of minimally and nondisplaced pelvic fractures can be treated nonoperatively.

      
      
   2. 
      

      See Chapter 30, Pelvic Ring Injuries, for a detailed discussion of initial and definitive treatment.

   
   
10. 
    

    Femoral shaft

    
    
    
    
    1. 
       

       Nonoperative treatment of femoral shaft fractures occurs in some third-world hospitals or in patients who are not amenable to operative treatment.

       
       
    2. 
       

       The results of Perkins’ traction (skeletal traction which allows movement of the knee) is reported to have a nonunion/malunion rate up to 10%, pin infection incidence of 30%, and an average hospital stay of 8 weeks.

       
       
    3. 
       

       Intramedullary nailing of femur fractures has been one of the great success stories of 20th century and is the standard of care even in remote hospitals with union rates > 98%.

    
    
11. 
    

    Tibial shaft

    
    
    
    
    1. 
       

       These fractures were commonly treated nonsurgically through the 1970s until intramedullary nailing became more popular.

       
       
    2. 
       

       Techniques such as long leg casting with wedging to correct angular deformity and transition to patellar tendon bearing casts and cast bracing were the standard of care.

       
       
       
       
       1. 
          

          Patients were placed in above knee long leg casts and switched to functional braces after 3 to 5 weeks.

       
       
    3. 
       

       Sarmiento reported a 2.5% nonunion rate and < 10% malunion rate in a series of 780 tibial fractures (241 were open).

       
       
       
       
       1. 
          

          Union occurred at an average of 17 weeks for closed fractures and 22 weeks for open fractures.

       
       
    4. 
       

       Generally acceptable parameters for closed treatment include < 5 to 10 degrees varus or valgus angulation, < 15 degrees in the sagittal plane, < 15 degrees internal rotation, < 20 degrees external rotation, and < 2 cm of shortening.

    
    
12. 
    

    Ankle fractures

    
    
    
    
    1. 
       

       Most unimalleolar nondisplaced ankle fractures are treated closed.

       
       
    2. 
       

       Unstable displaced ankle fractures are typically treated surgically.

       
       
    3. 
       

       Displaced ankle fractures can be treated nonoperatively if tibiotalar joint congruity is obtained following reduction.

       
       
    4. 
       

       Indications for closed treatment of ankle fractures include:

       
       
       
       
       1. 
          

          Isolated lateral malleolus fracture with < 4 mm medial clear space widening on external rotation or gravity stress views.

          
          
       2. 
          

          Isolated medial malleolus fractures where reduction can be maintained in cast.

          
          
       3. 
          

          Elderly low-demand patients or poorly controlled diabetics with high risk for surgical complications.

       
       
    5. 
       

       Displaced bimalleolar and trimalleolar ankle fractures should be promptly reduced even if surgical management is planned.

       
       
    6. 
       

       Typical reduction maneuver for a supination—external rotational injury with lateral talar displacement:

       
       
       
       
       1. 
          

          The Quigley maneuver classically describes suspension of the great toe with the patient supine. This facilitates reduction by adduction, internal rotation, and supination of the foot.

          
          
       2. 
          

          Treated with below knee casting for 4 weeks or longer depending on healing.