Introduction

Nonoperative management of fractures is presumably as old as humankind. One would therefore anticipate that as part of the evolutionary biology of humans that there would be an intrinsic ability for fractures to heal without surgical interference. Over centuries this has been demonstrated to be the case; fractures, left to their own devices, will heal and, even more importantly, this healing process is expedited by active use of the injured limb.

There has been an increasing tendency to treat surgically those fractures that might equally effectively be treated without open reduction and internal fixation. The reasons for this are multiple including more convenience for the patient and the surgeon, enjoyment for the surgeon (not the patient!), advertising by implant companies, and financial compensation for both surgeons and hospitals.

Although the surgical treatment by means of reduction and fixation of certain fracture types undoubtedly brings an added benefit to the patient, there are many fractures in which this is not the case. In a number of randomized clinical trials, the surgical treatment for common fractures has been proven to be no more effective than the nonsurgical treatment but at considerably greater expense to the system in terms of providing care. The common fracture-dislocation studies include fractures of the distal radius, fractures of the humeral shaft, fractures of the proximal humerus, fractures of the surgical neck of the humerus or acromioclavicular dislocations, fractures of the calcaneus, and some ankle fractures.

In the era of evidence-based medicine, it is perplexing and a bit disheartening to find that surgical procedures are routinely performed that do not bring benefit to the patient. Although this is not unique to fracture surgery or indeed to orthopaedics in general, it is an activity that should concern the thinking orthopaedic surgeon.

The nonsurgical management of fractures is technically demanding, time consuming, and requires more diligence then surgical treatment. Recognizing the benefits to the patient, however, makes it mandatory that every fracture that can be managed without surgery with an equal or better outcome to those treated by surgery should be considered for the nonsurgical option. Unfortunately, because of the increasing tendency to surgical treatment for virtually all fractures that could be managed nonoperatively, the ability to reduce, splint, and rehabilitate these fractures and the patients in whom they occur is becoming increasingly rare as the skill required atrophies by lack of use and training.

In North America and Europe, as well as parts of Asia, surgeons and patients have the luxury of opting for surgical or nonsurgical care. In many areas of the world, the so-called low- and middle-income countries (LMICs), the option for surgical management is frequently not available. Under these circumstances, nonsurgical management is the norm even for fractures that might better be treated by reduction and fixation. The ability to carry out good nonsurgical treatment in order to minimize patient disability is therefore imperative, and strategies to address fractures that would be routinely treated by reduction and fixation in the North American or European environment must be managed without fracture implants.

This chapter is being written so that there is a reference for the routine nonoperative management of fractures that do well with conservative treatment as well as to review the nonsurgical management of fractures that might ordinarily be treated by surgery were that option available. We have divided the section into upper and lower limbs addressing specifically the management of fractures of the scaphoid, distal radius, humeral shaft, and proximal humerus. All of these fractures are common, many of them can be treated in a very satisfactory fashion without surgery, and there is ample evidence to suggest that the outcome for nonsurgical management equals the results obtained by reduction and fixation.

In the lower limb, we focused on fractures of the ankle, many of which can be managed without surgery and added two special sections, one on the tibia and one on the femur.

The functional treatment of tibial shaft fractures results in a very high incidence of fracture union with excellent residual function. Its great advantage, of course, is the absence of infection and absence of complications related to fixation, such as nonunion, hardware failure, and anterior knee pain. The program for functional management of tibia fractures is rigorous, but if followed appropriately, excellent results can be anticipated without the expense or inconvenience of surgery.

The section on femoral shaft fractures will be of particular interest to those surgeons who do not have routine access to image intensification and intramedullary nailing. Treatment of femoral shaft fractures by means of traction is arduous for both the patient and the surgeon, but if done correctly, a very satisfactory outcome can be achieved in the great majority of patients.

We do not advocate nonsurgical treatment for those fractures that are best treated by surgery. What we do advocate is nonsurgical treatment for those fractures that do well when treated without surgery providing the treatment is appropriate and done correctly; as well, we hope to assist those surgeons and their patients who do not have access to routine surgical care.

I asked a number of individuals to write on these topics based on their interest and expertise. I think they did an excellent job in bringing together the disparate parts of nonsurgical management; their subjects are well referenced and amply illustrated.

In addition, the video that accompanies this text is very clear in detailing methods of reduction, splint application, and the application of traction.

I hope you enjoy this chapter.

Fracture Reduction and Maintenance of Reduction

I have studiously avoided the word “immobilization” for the conservative management of fractures. Immobilization in the real sense of the word does not take place. The only way one can truly immobilize a fracture is by rigid internal fixation. A fracture within a cast is subjected to the action of muscles attached to the fractured bone and whose actions pass across the fracture. They subject the fracture to recurrent stresses and movement. Provided only axial loading takes place and that angulatory rotational and shear stresses are minimized, the fracture will usually progress to union.

There are four recognized methods of reducing and maintaining reduction of fractures:

• 1.
  

  Manipulative reduction and plaster

  
  
• 2.
  

  Manipulative reduction and continuous traction

  
  
• 3.
  

  Manipulative reduction and external fixation

  
  
• 4.
  

  Operative reduction and internal fixation

Under certain circumstances, operative reduction may be used with plaster, traction, or external fixation to maintain reduction.

In general, closed reduction may be used for closed fractures, and operative reduction may be used for open fractures. The reason is that the soft tissue injury in compound fractures requires exploration by wound excision, often an extension to the main wound, to properly explore and excise the wound, and it seems logical in doing so to obtain an anatomic reduction of the fracture if possible. Perhaps the most common situation when this form of management could be used is in a tibial fracture. If the fracture is transverse or stable on reduction, the wound may be closed and plaster immobilization used. If, however, the fracture is grossly unstable, external fixation may be applied, anatomic reduction obtained, and then the wound closed. As with many tibial fractures, it may be found that the wound cannot be closed, and secondary closure or skin grafting may be necessary.

It must always be remembered that a limb is a functioning unit. The skeleton is the framework on which that function is based, and it depends on mobile joints, the activity of muscles and nerves, and an adequate blood supply. The object of fracture treatment is to restore the skeletal framework to as near normal as is possible after injury, thereby restoring a stable anatomic base on which the limb may function. Fracture treatment should be thought of therefore in three phases: phase 1, primary treatment; phase 2, definitive treatment; and phase 3, rehabilitation.

Phase 1 involves the initial treatment of reduction and fixation with plaster, traction, external fixation, or internal fixation followed by a period of rest and elevation to allow swelling and pain to subside. As far as possible within the limitations of treatment, early movement is encouraged to prevent the inevitable muscle wasting that occurs in the fractured limb and to minimize adhesion formation in relation to the area of the trauma and adjacent joints. This also promotes recovery of the blood supply and venous and lymphatic return by the action of the muscle pump.

Phase 2 commences with the application of a definitive cast or fracture brace after primary treatment by traction, cast, external fixation, or internal fixation. This should be applied in most cases between 10 days to 4 weeks to allow rehabilitation and more active use of the injured part, thus promoting recovery of function of muscle and nonimmobilized joints. Fracture bracing as far as possible does not immobilize joints and therefore allows a more complete recovery of muscle and joint function during this stage in recovery.

Phase 3, the phase of rehabilitation, commences with active mobilization after the application of a fracture brace and external or internal fixation of fractures. However, in patients treated by prolonged immobilization in a plaster cast or continuous traction until fracture union occurs, rehabilitation then commences. Very often a fairly long period of physiotherapy and exercise is needed to mobilize very stiff joints and build up wasted muscles and osteoporotic bones.

Manipulative Reduction

A famous orthopaedic surgeon once described manipulative reduction as “a little bit of this, and a little bit of that.” This, to say the least, is a gross oversimplification. It is essential to understand the pathologic anatomy of the fracture. For a fracture to become displaced, it requires either comminution of bone or periosteal damage to occur (or both of these things). The force required to reduce the fracture and the direction in which the force is to be applied depend on many factors. The simplest fractures to reduce are often comminuted fractures, but because of the nature of the fracture, they are inherently unstable. Oblique fractures of long bones are caused by a rotational force transmitted along the axis of the limb, and they often result in the spiking of the soft tissues by the sharp ends of the fragments. This inevitably leads to muscle interposition, and it is often impossible to bring about disimpaction completely. Transverse fractures occur because of a force applied at right angles to the diaphysis and are potentially stable fractures after reduction. The soft tissues on the side opposite the applied force are torn as the fracture takes place, and if the force is continued, then further displacement of the fracture occurs by periosteal stripping and muscle damage so that overriding of the bone occurs. This fracture can only be pulled out to length and reduced, either by tearing the remaining periosteal bridge as would occur using femoral distractor, or, as described by Charnley, by reproducing the angulatory displacement of the fracture to allow atraumatic reduction to take place ( Fig. 6B-1 ). Adequate preoperative assessment is essential. The patient is examined clinically for tell-tale signs of the mechanism of injury, such as skin damage caused by force of impact, and the radiographs are inspected in relation to this.

A, The intact periosteal bridge prevents reduction by longitudinal traction. B, Reproduction of the angulation of the injury allows the fracture to be reduced. C, Three-point fixation maintains reduction.

Types of Anesthesia

In certain circumstances, reduction and stabilization of the limb may be carried out by simply applying longitudinal traction to the limb. In general, it is wrong to attempt manipulative reduction of the fracture or dislocation without anesthesia. The normal response to injury is that the area is protected by muscle spasm, which has to be overcome or relaxed by anesthesia or analgesia to allow atraumatic reduction to be carried out. The stimulus for muscle spasm is pain, and this must be relieved. There are certain situations, such as when a fragment of bone, as a result of a severely displaced fracture or dislocation, is causing ischemia to the overlying skin or if the peripheral circulation is compromised, when the patient should be given intramuscular or intravenous analgesia and the limb repositioned or the dislocation reduced. Such examples are a severely displaced fracture-dislocation of the ankle in which the skin circulation locally is embarrassed or a knee dislocation with distal circulatory embarrassment in which reduction may allow the circulation to recover.

General anesthesia is the anesthetic of choice in modern, well-equipped hospitals. Under certain circumstances, such as when the patient is considered unfit for a general anesthetic, then local anesthesia or analgesia may be used. Local anesthesia injected directly into the fracture hematoma (e.g., in a Colles fracture in a frail elderly woman) can enable reduction to be carried out, but dangerously high levels of local anesthetic may appear in the general circulation.

Peripheral nerve blocks, brachial plexus blocks, or other regional blocks may be used for both upper and lower limb analgesia for treatment of upper and lower limb injuries. Brachial plexus anesthesia sometimes requires supplementation with more peripheral regional blocks or indeed local anesthetic into the fracture site. This produces analgesia from the mid upper arm distally and tends to be more effective the more distal the injury to the limb. Similarly, local blocks may be used in the lower limb. One of the most effective and simple blocks to administer is the femoral nerve block. This is carried out by introducing local anesthesia around the femoral nerve as it enters the thigh deep to the inguinal ligament. This produces excellent analgesia and muscle relaxation for reduction of femoral fractures. To insert a skeletal traction pin into the proximal tibia, it is necessary to supplement this with local anesthetic into the skin, periosteum, and muscle in the area.

Intravenous regional anesthesia fell into disrepute because fatalities occurred using lignocaine. Prilocaine (Citanest) has low systemic toxicity and is now recommended. During the procedure, the following precautions should be taken:

• 1.
  

  The patient should take nothing by mouth for 4 hours before surgery.

  
  
• 2.
  

  The procedure should be performed on a tipping trolley or an operating table.

  
  
• 3.
  

  There should be close supervision by a clinician experienced in the technique.

  
  
• 4.
  

  Venous access should be established in the opposite arm.

  
  
• 5.
  

  A resuscitation trolley must be immediately available.

  
  
• 6.
  

  The tourniquet must be regularly checked for leaks and should be observed constantly during use.

Ketamine has been used but does not produce muscle relaxation. Relaxants such as intravenous diazepam can have an unpredictable effect on patients, and some patients become hyperactive after its use. Entonox is also on occasion used to reduce dislocations and minor fractures but is also unsatisfactory. Midazolam is probably the most useful of this type of muscle relaxant. It is short acting and safe, and patients are always amnesic. Ideally, these drugs should only be used in experienced hands or when experienced help is readily available. A resuscitation trolley must always be instantly available.

Attempted reduction by the inexperienced without adequate analgesia or anesthesia can result in disaster for the patient. A very bad example seen by the author was that of an active, independent elderly woman referred to him with a comminuted fracture-dislocation of the shoulder in her dominant arm complicated by a complete brachial plexus injury. Before attempted reduction under Entonox on one occasion and diazepam on another occasion, the injury was a simple dislocation. Open reduction was necessary, a very stiff shoulder was the end result, and the brachial plexus injury did not recover.

Timing of Reduction

Reduction within a few hours after injury should be the aim in the treatment of both fractures and dislocations. Reduction of a dislocation normally produces immediate stability. If this is not the case, then this is almost certainly due to a concomitant fracture, which may require treatment by internal fixation. Reduction of either a fracture or dislocation, if not carried out soon after the injury, may be hampered by obstruction to reduction, by a firm blood clot, or edema of the acute inflammatory response. The ideal form of fixation for maintenance of reduction should be chosen.

Delay in fracture reduction until the next operating list is reasonable in most circumstances and is practiced in many centers (e.g., patients with fractures coming in during the night are dealt with the next morning). One must remember that the longer the delay in reduction, the more difficult it will be to obtain satisfactory reduction. If the fracture is not being reduced immediately, then it is essential to ensure that a satisfactory form of splintage is maintained for patient comfort and that the circulation is regularly monitored.

Some fractures cannot be reduced because of severe swelling; in these cases, it is inadvisable to attempt reduction. The classic example of this is a severe supracondylar fracture in a child when some form of traction and elevation of the limb should be used to maintain fracture position until the very tense fracture hematoma subsides. After a day or two after elevation, reduction of the swelling may allow manipulative reduction to be attempted if necessary.

Radiographic Examination of Fractures

Initial radiography of the fracture is essential to classify the fracture and to relate the type of fracture to the soft tissue injury. It is essential to have a good anterior-posterior (AP) and lateral view of the injury and to always include the joint above and below the fracture.

After manipulative reduction, it is essential to have a check radiograph in the operating room before the patient has been wakened up from anesthesia to ensure that a satisfactory reduction has been obtained. It is safer for the patient to be kept asleep for a few more minutes while the check radiograph is taken rather than waking the patient up and later finding that a poor reduction has been obtained. The patient will then have to undergo a further unnecessary general anesthetic. If image intensification is available, this is often useful, especially for screening potentially unstable joint injuries and difficult reductions. It saves time, but one must always remember that excessive screening should be avoided to minimize the dangers of radiation for the patient and the operator. In some situations, radiography may be unavailable, and one must therefore accept reduction as being present when the limb looks anatomically normal and the fracture feels stable to palpation. This is generally the situation when a check radiograph is available and it demonstrates that a satisfactory reduction has taken place.

External Support of Fractures

Nowadays there is a choice of a large number of materials for external splinting of fractures. Many modern water-activated bandages have been developed that are much stronger and more durable than plaster of Paris. There are also thermoplastic materials (Sansplint, Orthoplast, and Hexalite) made workable by heating in a water bath or oven that can be directly molded to the patient. All of these products are relatively expensive, but because of their light weight and durability, they are ideal for definitive casts and fracture bracing. The application technique for the water-activated bandages is very similar to that of application of plaster of Paris. However, the thermoplastic materials do require additional training and expertise for their application.

Management of Acute Fractures

The modern synthetic materials have no place in the management of acute fractures, and plaster of Paris remains the material of choice. The type of cast to be applied and the method of application depend on the severity of injury. A layer of cotton wool or synthetic padding that comes in rolled bandages of 4- or 6-in widths should be first applied to the limb below each cast. An injury caused by minimal trauma such as an undisplaced transverse fracture of the tibia with a small amount of swelling associated with it can have a snug cast applied early on. One layer of padding with at least two layers around the malleoli, heel, and foot may be used and a toe-to-groin cast applied with the knee in 10 to 20 degrees of flexion and the foot in a plantigrade position. On the other hand, a very severe injury or a crush injury with a lot of soft tissue damage and reactionary swelling should be treated in a cast with at least three layers of wool padding, and in addition, if there is a high degree of anxiety regarding the circulation, the cast should be split instantly from top to bottom, including the wool padding so that the skin is visible. This is especially important in compound fractures in which the wool may become blood soaked. When the blood dries, the wool then becomes rigid and may produce a tourniquet effect. Alternatively, a plaster slab can be used. This is made of eight to 12 layers of plaster depending on the size of the patient and wide enough to pass around the limb approximately half to two-thirds circumference. It is laid over the wool padding and bandaged in position using usually a fine mesh bandage. Again, in compound fractures, it may be necessary to cut it longitudinally anteriorly from top to bottom. Always remember it is more important to apply extra padding over bony prominences such as the malleoli, heel, and foot and the head and neck of the fibula than around the muscular parts of the limb.

For the application of a definitive cast, only stockinette or one layer of wool padding may be used with appropriate padding over bony prominences. The usual casting positions are as shown in Figure 6B-2 .

A, Forearm cast for treatment of injuries or fractures to the forearm and wrist. It extends from the metacarpal heads to below the elbow. The plaster must not reach beyond the distal palmar crease (two views). B, Long arm cast for immobilization of the elbow and treatment of fractures around the elbow and of the forearm. The elbow is at 90 degrees, the wrist is in slight dorsiflexion, and the forearm is in the appropriate position of pronation/supination (one view). C, Long leg cast for treatment of fractures and injuries around the knee and fractures of the tibia and ankle. The knee is in 10 to 15 degrees of flexion with the foot plantigrade, that is, sole of foot at 90 degrees to the front of leg (one view). D, Below-knee cast for treatment of injuries of the ankle and foot. On the sole, the plaster must go beyond the metatarsal heads, and for a walking cast, the foot must be plantigrade (two views).

The definitive stages of applying a below-knee cast are shown in Figure 6B-3 . Clearly, the limb must be supported in whatever way is necessary to maintain the position of the fracture during application of the cast. For a definitive cast, a layer of stockinette is first applied and will hold any necessary dressings in position ( Fig. 6B-3 , A ). Wool is then applied from the metatarsophalangeal joints of the toes to the head of fibula, with an extra layer of wool applied around the malleoli, heel, and foot The casting material is then applied starting at the narrowest point in the limb to avoid drift of the bandage, and it is rolled firmly onto the contours of the limb to ensure snug contact and without applying undue pressure ( Fig. 6B-3 , B ). It is rolled on in such a way counting the layers applied so that even layers of bandage are applied from the top of the cast to the bottom of the cast. For the fiberglass materials, usually two lengths of 10- or 15-mm bandage are enough to complete a cast. If plaster of Paris is used, which is the cheapest material per bandage, probably four to six bandages will be required for the average below-knee cast. It is important after application of each bandage to work the resin or the plaster of Paris through the bandage by smoothing it all the way up and down with the flat of the hand. This must be done when the material is still soft before curing or hardening of the material takes place.

A, Leg with stockinette applied. Wool is then applied around the head of fibula to protect the popliteal nerve and around the malleoli, heel, and foot as far as the metatarsal heads. B, Material is rolled on starting at the narrowest part of the limb. C, A finishing layer with stockinette folded back at the appropriate level to cover rough edges.

Before the last layer of bandage is put on, the stockinette is folded back to make a nice padded, rounded edge to the bandage, and in doing so, the casting material can be rolled back to the appropriate level. The bottom end of the cast should be obliquely shaped, covering the metatarsal heads and the sole of the foot and allowing free movement of all the toes. The upper end of the cast should finish just below the knee, allowing free knee movement ( Fig. 6B-3 , C ). It is essential at all stages of the process to hold the relative positions of the foot and leg in a plantigrade position, which is the position of function for walking. If the exact position is not maintained throughout the process and at some point the position of the ankle has to be changed, then folds or tucks will appear in the wool or the bandage itself, which will create high-pressure areas within the cast and may well cause cast sores. In plaster of Paris casts, it is important to remember that the strength of the cast is in the crystal lattice, which builds up during the hardening process. If any molding or changing of position of the cast is carried out while this is happening, then this will not allow a strong crystal lattice to build up, and a weakened cast will result.

Application of Three-Point Loading Techniques

In certain fractures such as bimalleolar or lateral malleolar ankle fractures with lateral talar shift, and Colles fractures, a three-point loading technique may be used to maintain fracture position. Both of these fractures are liable to redisplacement as the swelling goes down and the cast becomes loose and can be avoided by three-point loading. To do this, one applies a full cast quickly with the help of a colleague. While the plaster is still in the creamy state, using the flat of one’s hand and avoiding the application of local pressure over bony prominence, three-point loading may be applied to the upper and midpoints of the cast and over either the lower end of radius or lateral malleolar areas ( Fig. 6B-4 ). The loading built into the cast ensures that as the swelling subsides, sufficient loading remains to maintain the fracture position. This has been proven to be a viable technique in the case of Colles fractures while at the same time leaving the wrist free to move.

A, Diagrammatic presentation of three-point loading in a long leg cast. B, Long leg cast with built-in loading. This is applied with appropriate layers of plaster wool applied the whole length of the cast from the toes to the groin. Plaster is then applied from the groin to two-thirds of the way down the leg and allowed to harden. More plaster is then applied overlapping the hardened cast at the join from the knee to the toes. As this portion of the cast hardens, three-point loading is applied using the flat of the hand at the mid or upper calf level and flat of the other hand at the ankle level. It is possible to apply loading with the foot held in a plantigrade position, remembering to avoid high pressure over the bony prominence of the lateral malleolus.

Postreduction Management of Acute Fractures

Elevation and early mobilization are of utmost importance. Elevation is done to reduce the possibility of further swelling and enhance the dissipation of swelling already present. Early active movements must be encouraged not only in the injured limb itself but also the patient as a whole. He or she must be reassured that early movement is not harmful and is instead beneficial to the healing processes and in doing so helps reduce swelling and prevent joint stiffness.

In all patients, after application of a cast, it is essential in the first 24 hours to make the necessary checks of the circulation. For minor fractures, the patient should be advised to see a doctor or nurse the morning after or return to the emergency department (ED) to have the circulation and the cast checked. It is customary in most EDs for patients to be given instructions with them ( Fig. 6B-5 ). These are sometimes attached to the cast in a position in which they can read them; these instructions give general advice regarding the cast. When patients are kept in the hospital for elevation and there is a genuine worry regarding circulation, then the circulation should be checked as often as is necessary for 24 to 48 hours. Adequate levels of analgesia should be given to control pain and in doing so will encourage activity.

Patients’ plaster instructions (general).

Wedging of Casts

Fracture angulation may be corrected by wedging the cast. The timing of wedging is important; in general, it is better to obtain the optimum fracture position as early as possible. However, wedging of unstable fractures may simply cause displacement and require remanipulation. On the other hand, if one waits until the fracture hematoma has clotted and early organization has taken place at 2 to 3 weeks, then significant displacement is unlikely to occur. Alternatively, the angulation may be corrected during the application of a definitive cast.

Accurate wedging is carried out by dividing the cast two-thirds of its circumference on the concave or inner angle of the fracture and then opening up the cast. This is done by lining up a piece of paper or a T-square with the distal fragment and keeping the piece of paper parallel with it, mark a point on the convex side of the cast and the concave side of the cast at the fracture level. The piece of paper is reversed, aligned with the proximal fragment and the mark on the cast on the concavity of the fracture and another mark made on the cast outline opposite. Two points will result on the cast outline on the convex side of the fracture. A measurement of this is the amount by which the cast should be opened ( Fig. 6B-6 ). It is the author’s experience that if these measurements are taken, then very accurate correction of the angulation takes place (see Fig. 6B-6 ). The cast should be finished by filling the wedge with a piece of plaster or material cut to the size of the wedge and laid into the space filling it completely. The standard method of wedging is to open the wedge, cut a block of wood of appropriate size, and insert it into the wedge to hold it open while a check radiograph is taken. If a block of wood is present, this should be removed, and the cast finished off as discussed. Finally, one or two plaster bandages are wrapped around this to complete the cast. If this procedure is used, then a very strong and durable cast is produced.

Wedging of a cast by calculation from the radiograph ( A ) and the correction obtained ( B ).

If angulation is present in both AP and lateral planes, then the position of the wedge “hinge” should be rotated so that it lies opposite the true convexity of the fracture angle. The amount to which the wedge should be open is then calculated from the AP and lateral radiographs as described earlier and the opening calculated according to the degree of rotation.

Walking Casts

Gait analysis of walking casts has demonstrated that a normal gait pattern is present in patients with below-knee walking casts with the foot in a plantigrade position, that is, with the flat surface of the foot or cast at 90 degrees to the front of the leg. The foot in any other position will lead to an abnormal gait pattern. Therefore, for the patient to recover a normal walking pattern after injury, it is essential that a walking cast has the foot applied in a plantigrade position. There are many appliances available on the market; many of them produce an abnormal gait pattern because they are too thick and elevate the fractured limb higher than the patient’s normal shoe, or they are simply unnatural. A simple walking cast shoe such as the Aberdeen boot is ideal ( Fig. 6B-7 ). The action of walking in a below-knee cast tends to cause breakdown of the heel and sole of the cast because these areas are subjected to recurrent impact forces and are areas of high stress. In addition, because the heel and sole are on the convexity of the ankle, the cast is thinner in this area. The sole and heel of the cast may therefore be strengthened with a slab of an appropriate casting material, and this can also be extended to above the ankle, which is also sometimes an area of cast breakdown. In addition, one-fourth Plastazote is a useful buffer to apply over the area of the sole and heel to help absorb the impact of walking.

Aberdeen boot. Water-resistant material in an upper with a thin sole of nonslip material.

Incidence and Demographics

Scaphoid fractures are the most common bone of the carpus to be fractured and occur most frequently in young men (85%) between the ages of 18 and 35. Wolf’s study used a public database of acute injuries within the United States and found that there is a male preponderance with 66.4% versus 33.6% females. Hove’s series showed 225 of 330 total scaphoid fractures to have occurred in males, which is a predominance of 82%. Van Tassel and colleagues showed a male predominance of 66.4% but nearly one-third of scaphoid injuries occurred in girls and women. This higher incidence in females, which was found in comparison to previous studies, was postulated to be perhaps caused by an increase in participation in organized sports. The typical mechanism of injury is a fall on outstretched hand (FOOSH) with experimental studies showing extreme dorsiflexion (greater than 95 degrees) coupled with compressive force to the radial side of the wrist can result in fracture of the scaphoid. Also some researchers believe a fall backward with the hand directed anteriorly is most likely to result in extreme dorsiflexion of the wrist. These falls of relatively low energy make up the majority of scaphoid fracture mechanisms.

Other mechanisms of injury would include any high-energy trauma involving the wrist, and more rarely, a direct blow to the scaphoid can also result in fracture. Historically, this was described as a “crank-handle kickback,” which because of the high forces involved, often resulted in displaced oblique or unstable scaphoid fractures.

Given the important role of the scaphoids in hand and wrist function, prompt diagnosis and appropriate management is key in minimizing potential complications, such as nonunion, avascular necrosis, and subsequent osteoarthritis with or without development of a scaphoid nonunion advanced collapse (SNAC) and dorsiflexed intercalated segment instability (DISI) or volar intercalated segment instability (VISI) deformities. Typically the mechanism of injury and patient type will lead the clinician to have a high index of suspicion.

Clinical Examination

Thereafter, a thorough clinical examination should involve examination of the upper limb including elbow, palpation of the bony landmarks around the wrist and hand paying particular attention to tenderness elicited on palpation of the anatomic snuffbox. The boundaries of the anatomic snuffbox are posteriorly the tendon of extensor pollicis longus and anteriorly the tendons of extensor pollicis brevis and abductor pollicis longus.

The proximal border is the styloid process of the distal radius and the distal border by the apex of the tendons giving the anatomic snuffbox an isosceles-triangle shape. Snuffbox tenderness is frequently taught as a clear sign of scaphoid fracture, but although it has a high sensitivity, it has been shown to have a relatively low specificity in diagnosing scaphoid fractures.

General examination may reveal bruising, or an effusion and tenderness on palpation of the scaphoid tubercle is highly suggestive of scaphoid fracture. Radial deviation of the wrist alters the scaphoid position so that the tubercle becomes prominent on the radial side of the volar wrist crease allowing for palpation.

Other clinical tests include the scaphoid compression test, which Chen found to have great sensitivity and specificity in diagnosis of scaphoid fracture. Studies performed in other institutions have shown poorer specificity.

The scaphoid compression test is performed by holding the thumb of the affected wrist in one hand while stabilizing the forearm with the other hand. A compressive force is applied with pain providing a positive result.

Forced deviation maneuvers of the wrist should probably be avoided as they will more than likely result in pain in the acute setting while yielding little clinical information.

Radiologic Examination

After a thorough careful examination, plain radiographs should be performed. In most institutions, this will include four views of the wrist. These should be (1) a posterior-anterior view with the wrist in ulnar deviation, (2) a true lateral, (3) a semipronated oblique, and (4) a scaphoid view with the wrist pronated in ulnar deviation with the x-ray beam 25 degrees off vertical directed cephalad.

Leslie and Dickson reported that, in a series of 222 scaphoid fractures, 98% were visible on radiograph film at first examination. The remaining 2% became visible after 2 weeks. Other authors reported less optimistic figures—as low as 84% visible on first examination.

The key is to get one clear view profiling the trabeculae of the scaphoid, which can then be thoroughly examined. On older standard radiographs, some surgeons advocated the use of a magnifying glass to examine the trabeculae, but most images can be now be manipulated digitally. The scaphoid fat strip (SFS) is a radiolucent stripe adjacent to the radial side of the scaphoid and can be displaced in the presence of a fracture. Radial convexity or obliquity of the SFS are considered pathognomonic of a fracture similar to the posterior fat pad sign of the elbow.

Clenched-fist views can be used if suspicion of a scapholunate injury exists. The intrascaphoid angle is the intersection of two lines drawn perpendicular to the diameters of the proximal and distal poles. Amadio and colleagues used a trispiral computed tomography (CT) scan and two techniques to delineate abnormal values of more than 45 degrees. Bain and coworkers described that the height-to-length ratio of the scaphoid was the most reproducible way of measuring the humpback deformity that could be used to indicate collapse. The height-to-length ratio should average less than 0.65. A greater ratio indicates collapse of the scaphoid.

Four bony parameters that suggest displacement are translation, gap, angulation, and rotation. Conventionally, a fracture is considered displaced if the gap is 1 mm or more.

On occasion, in the acute phase, up to 25% of scaphoid fractures can be radiographically occult. Patients with clinical mechanisms of injury and clinical examination findings suggestive of scaphoid fracture are normally placed in cast immobilization and brought back for either repeat radiographs or further, more specialized imaging. At 2 weeks, when repeat radiographs are performed, radiographs may show bone resorption at the fracture sight making the nondisplaced fracture more visible. If the fracture shows signs of having displaced, then it declares itself as unstable and potentially suitable for operative fixation.

An international survey of hospital practices revealed marked inconsistency in acute scaphoid imaging protocols. The authors believed this is probably caused by various factors but also attributed it to a deficiency in scientific evidence on the matter. A recent meta-analysis by Zhong-Gang and colleagues investigated imaging modalities used in diagnosing scaphoid fractures. A systematic review and meta-analysis was performed that assessed and compared the available imaging modalities. These included bone scintigraphy, magnetic resonance imaging (MRI), and CT. They found that bone scintigraphy and MRI have equal sensitivity and high diagnostic value for excluding scaphoid fractures; however, MRI is more specific and better for confirming scaphoid fracture.

Classification and Fracture Incidence

In general, the fracture of the waist is the most common of scaphoid fractures (70%) with distal pole fractures at 10% to 20%, proximal pole fractures at 5%, and tubercle fractures at 5%. Bindra studied cadaveric scaphoid with CT scanning and found that the bone is most dense at the proximal pole, where the trabeculae are the thickest and are more tightly packed, whereas the trabeculae in the waist are thinnest and sparsely distributed.

Classification systems should be reproducible, aid in decision making regarding treatment, and give information on prognosis. The Herbert classification has been shown to have good interobserver reliability and reproducibility as well as helping to determine treatment. The classification system attempts to define stable and unstable fractures, with Herbert type A being an acute stable fracture and Herbert type B being an unstable fracture.

Stable fractures include fractures of the tubercle and incomplete fractures of the waist. These fractures can potentially be treated conservatively, which will be discussed further in the following section; the unstable fractures normally require surgical intervention.

Treatment Options

Cast Treatment

Before radiographs were invented, fracture of the scaphoid was poorly understood and difficult to manage. In the early 1900s, treatment consisted of brief splintage followed by massage and early mobilization. The poor results of this technique led to development of different types of immobilization. From 1925 to 1941, Bohler used a simple back slab leaving the thumb free, and then from 1942, included the thumb. By 1954, he had treated 734 fractures, and of the 580 available for review, only 4% failed to unite.

This drastic increase in union and decrease in morbidity, as well as the observation by Bohler and others that nonunion is more common when treatment is delayed, led to many favoring conservative management of scaphoid fractures.

The observation of very low nonunion rates following immobilization alone has not been universal and led to a variety of cast types being used by different surgeons. Soto-Hall found in cadaveric studies that any movement of the interphalangeal joint of the thumb led to a definite change in fracture fragment position. He felt this could be eliminated by immobilization of the thumb up to the base of the thumb nail and reported 95% union rates using this method ( Fig. 6C-1 ).

A, Stockinette and cast paper for scaphoid cast. Notice that the metacarpals are free and the thumb is wrapped up to the interphalangeal (IP) joint. B, Lateral view showing the finished cast. C, The IP joint of the thumb is free; metacarpal-phalangeal joints of the fingers are free. D, Note full finger flexion.

It is difficult to establish exactly when inclusion of the thumb became known as a “scaphoid cast” and the belief that the thumb should be immobilized is yet to be definitely shown by a study. Given the relatively low rate of nonunion in scaphoid fractures, a study demonstrating significantly increased union rates would have to have large numbers and be rigorously designed.

In their study, Clay and colleagues found union rates to be roughly equivalent when comparing thumb immobilization with a Colles cast and concluded that for “fresh, undisplaced fractures of the waist of the scaphoid, the simpler Colles cast would appear to be equally as effective.”

Despite this, it remains a controversial matter, and many surgeons tend to err on the side of caution in immobilizing the thumb and using below-elbow casts, as convincing evidence of the benefit of above-elbow cast has not been shown.

A recent meta-analysis by Alshryda and colleagues examined this topic. They found that only one trial compared Colles cast versus scaphoid cast. The trial recruited 291 patients and showed no significant difference between the two groups.

Two studies compared above-elbow versus below-elbow casts and had insufficient data for meta-analysis. There was no statistical difference in the union rate, complication rate, or time to union.

One study investigated the position of the wrist in a Colles cast and found that there was not a significant difference in union rate. They found there were more complications and less grip strength in the flexed wrist group but that these differences do not reach statistical significance.

Only one study was identified that examined the use of adjunct ultrasound treatment with standard scaphoid cast and found no difference in union rate but that the ultrasound group had a significantly shorter time to union by approximately 19 days.

A recent study by Hannemann and coworkers, investigating the use of pulsed electric magnetic fields in the treatment of scaphoid fractures, showed no benefit in their use with similar union rates and times to union in the control group.

Conclusion

The authors advocate nonsurgical treatment for nondisplaced fractures of the scaphoid. Minimally displaced transverse fractures of the waist of the scaphoid may be treated closed or with reduction and fixation. This should be decided on an individual basis with the patient in terms of the patient’s expectations, tolerance for surgery and its complications, and functional demands of the patient’s wrist. Displaced scaphoid fractures, scaphoid fractures associated with subluxations, and/or dislocations of other carpal bones and delayed presentations of scaphoid fractures longer than 4 weeks should, as a general rule, be treated surgically.

Demographics

Distal radius fractures are one of the most common fractures with more than 640,000 cases reported in 2001 in the United States alone. The annual incidence of distal radial fractures in the U.S. population older than 65 years of age has been reported to be 57 to 100 per 10,000. The exact reason for the current trend toward increasing incidence is not fully understood but among other factors, includes an aging population with less sedentary pastimes.

The overall impact on society of this large number of patients with fractures of the distal radius is direct and indirect. The cost of medical care from assessment through conservative or operative treatment and all the costs that entails would be considered direct costs. For example, in 2007, Medicare paid $170 million in distal radius fracture–related payments. Perhaps even more important to consider would be the indirect costs of decreased school or work attendance, loss of work hours, loss of independence, need for care, and potential lasting disability.

Lack of homogeneous coding and databases at all hospitals treating these fractures makes the true number of these fractures difficult to estimate with the true number being potentially much larger than that just mentioned.

Distal radius fractures can affect anyone of any age but their incidence falls into three main age groups: children and adolescents, young adults, and the elderly. Gender and ethnicity can also play a part in determining risk.

Demographic studies have shown that distal radius fractures account for 1.5% to 2.5% of all emergency department attendances.

One study showed that 32% of all fractures seen in women older than the age of 35 years are of the distal radius and that distal radius fractures can account for up to 18% of all fractures in the over-65-years age group. It has also been shown that the overall lifetime risk of a distal radius fracture is 15% for women and 2% for men.

Clinical Assessment

As with any musculoskeletal injury, initial assessment should focus on the Advanced Trauma Life Support (ATLS) guidelines, and subsequent history and examination should be tailored according to the findings of the primary and secondary survey. Special consideration should be given to certain patient subgroups regarding the mechanism of injury, for example, in the pediatric population to exclude nonaccidental injury (NAI) and in the elderly population to determine the underlying reason for the fall.

The mechanism of injury also allows the clinician to begin to build a picture of the underlying bone quality and injury to the surrounding tissues, both of which may alter the treatment strategy.

Once a full history and assessment have been made, if an obvious deformity is noted, then at the least, the limb should be splinted after analgesia and potentially manipulated depending on the circumstances. Rings and other jewelry should be removed. Careful neurovascular examination should be performed and if any abnormality is found, it should be carefully documented and emergent treatment should be undertaken to reduce the fracture and address the neurovascular compromise.

Open fractures should be treated as per local protocol with wound irrigation, photography, dressing, tetanus prophylaxis, and intravenous antibiotic administration. Special attention should be paid to farmyard injuries and aquatic injuries, which may require special antibiotics on the advice of the microbiologist.

Radiologic Assessment

Accurate and appropriate radiographs and their interpretation can play a large part in providing surgeons with information on which to base their treatment plans.

Normal radiographic evaluation of the distal radius should include a posterior-anterior (PA) and true lateral projection. Also a modified lateral view with the beam angled 10 degrees proximally should be performed to assess fracture reduction and provide more detail about the articular surface.

PA radiograph allows assessment of the radial styloid, articular surface of the distal radius, proximal and distal carpal row, distal radioulnar joint, and distal ulna.

A true lateral projection is essential for basing further management. Occasionally, radiographic technicians can place the arm in extremes of pronation or supination; simply superimposing the radius on the ulna can result in an oblique view of the articular surface. A simple method to avoid this is to use the relative position of the pisiform to the distal pole of the scaphoid as the reference for judging the quality of the lateral radiograph—the “scaphopisocapitate alignment criterion.” On a true lateral radiograph, the pisiform should overlap the distal pole of the scaphoid. If the pisiform is positioned dorsal to the distal pole, then the forearm is in relative pronation, and if the pisiform is volar, then the forearm is supinated.

In a standard view, the radiograph is perpendicular to the shaft. Because the radial inclination of the ulnar two-thirds of the articular surface is 10 degrees, this results in an oblique view of the joint surface on standard lateral radiograph. The 10-degree lateral tilt projection allows more accurate assessment of the articular surface, identification of the apical ridges of the dorsal and volar rims, and the teardrop. Basic parameters measured on the lateral radiograph would be volar tilt, carpal alignment, and cortical integrity. On the PA view, standard assessment would include radial height, inclination, ulnar variance, and assessment of the visible carpi.

Normal Parameters

See Table 6D-1 for the normal parameters, as described by Medoff and colleagues in 2005.

How Much Deformity is Acceptable in Adults

As will be repeated throughout this chapter, a wide variety of literature exists regarding this matter but few papers can convincingly demonstrate a link between degrees of malunion and decreased function, increased pain, or long-term risk of arthrosis.

Short and coworkers have shown an increase of 18% to 42% of forces borne by the distal ulna with a relative shortening of as little as 2.5 mm. As the radius shortens relative to the ulna, the triangular fibrocartilage complex (TFCC) becomes tighter, and this can lead to pain at the distal radial ulnar joint (DRUJ) and decrease forearm rotation.

Shortening of 6 to 8 mm can cause ulnar impingement on the triquetrum or extreme ulnar border of the lunate. Bronstein and colleagues found 10 mm of shortening resulted in a mean 47% loss of pronation and 29% loss of supination. The DRUJ was effectively locked by ulnocarpal abutment at 15 mm of shortening.

It could be argued that there is a general agreement that shortening of greater than 5 mm is associated with poorer outcomes.

Dorsal angulation is very commonly observed in distal radial malunions, but despite this, there appears to be widespread differences of opinion about what constitutes an acceptable value. As angulation increases, the load increases from volar-radial to dorsal-ulnar. In a cadaveric study, Short and colleagues demonstrated that the load through the distal ulna increased from 21% at 10 degrees of volar tilt to 67% at 45 degrees of dorsal tilt. At 30 degrees of dorsal tilt, 50% of the load was borne by the ulna.

Miyake and coworkers concluded that osteotomy to address abnormal wrist loading should be conducted when dorsal angulation exceeds beyond 20 degrees.

Lafontaine and colleagues identified several risk factors associated with secondary fracture displacement despite a satisfactory initial reduction. These included the presence of dorsal tilt greater than 20 degrees, comminution, intraarticular involvement, an associated fracture of the ulna, and age older than 60 years.

Graham defined acceptable parameters of the distal radius as ulnar variance of less than 5 mm compared with contralateral wrist, radial inclination on the PA radiograph greater than 15 degrees, and tilt measured on the lateral radiograph as between 15 degrees dorsal and 20 degrees volar.

Relatively recent American Academy of Orthopaedic Surgeons (AAOS) guidelines state acceptable figures of less than 5 mm of radial shortening at the DRUJ compared with the contralateral side, radial inclination more than 15 degrees on PA radiographs, sagittal tilt on the lateral projection between 15 degrees dorsal tilt and 20 degrees volar tilt, intraarticular step-off or gap of less than 2 mm, and articular incongruity less than 2 mm of the sigmoid notch of the distal radius.

Treatment

In the majority of cases (as described in the next paragraphs), a well-executed closed reduction using analgesia with or without sedation as per local protocols and skill levels is nearly always indicated. Adequate analgesia should be administered in a controlled and safe manner prior to attempts at reduction and casting. Analgesia can range from nitrous oxide, routine oral analgesia, local anesthetic hematoma block, Bier block, conscious sedation, or general anesthetic. The best technique for reducing a fracture is to replicate the deformity, apply traction, and then manipulate it into appropriate position. A well-molded cast with three-point molding should be applied and radiographs in the cast obtained ( Fig. 6D-1 ; see video 6D-1). The authors repeat radiographs at 1 week and at 2 weeks to assess for displacement. They then reassess the patient at 6 weeks for removal of the cast and obtain radiographs plus offer referral to physical therapy for rehabilitation if clinically indicated.

A, Note finger traps: These are used to help obtain and maintain reduction. They allow the application of plaster without the need of an assistant. B and C, Note the thumb, index, and middle fingers in the finger traps. A counterweight of 2.3 kg (5 lb) is applied to the arm just above the elbow. Stockinette is applied to the forearm prior to inserting the fingers in the finger traps. Cast paper is then applied. Overall view of the appearance of the forearm: Note the finger traps maintain ulnar deviation of the wrist. D, Volar plaster slab is applied over the stockinette and cast paper. E, A dorsal slab is applied ensuring that there is an open space along the ulnar border of the forearm. F, The slabs are held in place with a nonelastic gauze bandage. G, Slabs are then covered with a 4-inch flannel bandage. H, Note the space on the ulnar side of the forearm between the plaster slabs, which allows for easy relief of the cast should swelling occur.

I, With the reduction maintained in the finger traps, molding occurs: Note the palmar molding hand is over the proximal fragment and the dorsal molding hand is over the distal fragment. J, The finished immobilization. Note the thumb and fingers are free to promote hand use.