Chapter 6: Principles of Nonoperative Fracture Treatment

Charles M. Court-Brown

Chapter Outline

Introduction

Nonoperative fracture management was the only method of fracture management until about 1750. Since then there have been advances in operative fracture treatment, which accelerated considerably after World War II because of improved surgical techniques, better anesthesia and postoperative treatment, and the introduction of antibiotics. Even today, nonoperative management remains a very important tool in the armamentarium of the orthopedic trauma surgeon. The concentration of severe injuries into specialized trauma centers in many countries has unquestionably improved their treatment but has also caused surgeons to overestimate the role of operative treatment in the full spectrum of fractures. In fact, nonoperative fracture treatment remains the most common method of fracture management, although its role has changed significantly during the last 30 to 40 years. This chapter presents an epidemiologic analysis of nonoperative fracture management from a major trauma center, illustrates common nonoperative techniques, and discusses indications for their use. 

History of Nonoperative Fracture Treatment

The ancient Egyptians were the first to document how fractures should be managed and to record the basic results of their management69 The Edwin Smith Papyrus dates from 2800 to 3000 BC and was translated in 1930 in the United States.12 It is composed of a series of case reports of specific injuries and their associated prognoses, good and bad. Case 37 describes a coexisting humeral fracture and wound over the upper arm. It suggests that if the two are not connected the arm should be splinted and the wound dressed. If the wound and fracture connect the prognosis is poor and the ailment should not be treated! In those days, splintage relied on bandaging over splints of wood and linen and using glue to stiffen the bandages. 
There does not appear to have been any significant advance in fracture management until the Ancient Greek Empire, with Hippocrates being credited with many advances that were probably the results of clinical work of many doctors. Hippocrates described six different methods of applying roller bandages depending on the fracture location. The bandages were stiffened with cerate, which was an ointment consisting of lard or oil mixed with wax, resin, or pitch to essentially create a cast. It was customary to defer definitive management, usually fracture manipulation, until the swelling had diminished, which often took about 7 days. It is interesting to note that delayed management still remains popular in the treatment of some fractures. The Ancient Greeks also used mechanical aids to facilitate the reduction of fractures and dislocations, and Hippocrates is credited with the first audit of fracture healing time. However, he was either an optimist or the ancient Greeks had a superior genetic makeup because he said that femoral fractures and tibial fractures united in 50 and 40 days, respectively!45 
Further progress occurred in Ancient Rome and in Asia, but it is Albucasis, an Arabic physician, who is credited with advancing nonoperative fracture treatment and for acting as a conduit through which the philosophies of Ancient Rome and Greece could be transferred to Western Europe. Albucasis clearly upset his colleagues by suggesting that in femoral diaphyseal fractures the knee should be placed in full flexion.69 His cast was a mixture of mill dust and egg whites or mixtures of grain, herbs, clay, and egg whites that were supported by bandages. He also introduced the somewhat radical practice of maintaining his casts for a longer period rather than changing them every few days, as had been done up to that time. 
Following the introduction of gunpowder in 1338 AD, cannon shot in 1346 AD, and half-pound gunshot in 1364 AD, it was obvious that surgeons were going to be faced with many more open fractures than they had encountered before. As one would expect this stimulated innovation and surgeons began to challenge the views that open wounds should be encouraged to suppurate and that “laudable pus” was essential for wound healing. Paré and others demonstrated that wounds could be cleaned and sometimes closed primarily. Paré made the discovery that primary wound cleaning using a paste of oil of roses, turpentine, and egg yolk gave better results than the use of boiling oil. Paré’s views were very influential, and the management of open wounds improved considerably.2 He and others realized that devitalized bone fragments should be removed from open wounds but it was Desault and Larrey who introduced debridement at the l’Hotel Dieu in Paris at the end of the 18th century.69 
Despite considerable progress being achieved in the management of open wounds, surgeons were essentially still left with the fracture treatment principles outlined by Albucasis around 1000 AD. Seutin,87 a Belgian surgeon, had introduced a method of applying rigid dressings which could be left in position for a longer period, but it was the introduction of plaster of Paris bandages that revolutionized fracture treatment. These were introduced by Pirogov from Russia and Mathijsen from Holland in the early 1800s.69 A better method of fracture management had become essential because of the carnage caused by the Napoleonic wars in Europe and the increased urbanization associated with the Industrial Revolution. While plaster of Paris bandages were not used during the American Civil War, Sayre85 and Stimson93 in New York together with Scudder86 in Boston promoted the use of plaster of Paris bandages in the United States. Volkmann103 was a particular enthusiast of the use of plaster of Paris in the management of fractures in Europe. 
As with all new inventions, it took time for most surgeons to accept plaster of Paris bandaging, and the use of supportive splints such as the Thomas splint remained popular in the United Kingdom. They were strongly supported by Thomas94 and Jones.50 Eventually plaster casts became the routine method of managing most fractures and the arguments between surgeons centered around the amount of padding that should be used, the use of early weight bearing, and whether early joint motion could be allowed. Lorenz Böhler of Vienna7 was a particular proponent of plaster of Paris cast treatment, believing in accurate reduction, the use of skintight casts, and intensive physical therapy. He was also very influential in developing a system of fracture treatment that was adopted throughout the world. 
Sarmiento8084 was a particular advocate of nonoperative management, particularly of tibial fractures. He introduced a lower leg functional brace to permit early joint mobilization. Credit must be given to Sarmiento for continuing to popularize nonoperative management of diaphyseal fractures and for providing a counterargument to those surgeons who felt that operative management was always indicated. Sarmiento’s tibial functional brace became popular but its introduction coincided with the explosion of interest in operative lower limb fracture treatment, which started in the 1960s. 
The operative treatment of fractures first started around 1775 in France, and the first operative textbook detailing techniques of fracture fixation was published by Bérenger-Féraud in 1870.6 He described six methods of fracture management, of which three are still in use today—cerclage wiring, interosseous sutures, and external fixation. In the 20th century operative management rapidly increased in popularity in both the United States and Europe. Pioneers such as Lambotte, Hey-Groves, Lane, Hoffman, Küntscher, Ilizarov, and Müller and his colleagues in Europe and Parkhill, the Rush brothers, and Sherman in the United States promoted internal and external fixation.69 However, it was the introduction of antibiotics and the development of modern anesthesia and improved surgical techniques that altered the way orthopedic surgeons considered fracture management. The prevalence of operative fracture management has now increased significantly but it is not used in all fractures. It is instructive to review the current use of nonoperative fracture management and to compare it with 50 or 60 years ago, when many surgeons were beginning to think seriously about operative management for the first time. 

Epidemiology of Nonoperative Fracture Treatment

There has been no previous study of the use of nonoperative management in a defined population of adults, although there have been studies of the use of nonoperative treatment in more specialized hospitals, which were not responsible for treating all fractures in an entire community.31,39,59,95 These studies have mainly dealt with pediatric fractures39,59,95 but in 1958 Emmett and Breck31 published a paper detailing the treatment of almost 11,000 fresh fractures in El Paso, Texas. To analyze the current role of nonoperative management, a study of the primary treatment of 7,863 consecutive fractures in Edinburgh, Scotland, in 2000 was undertaken. To allow the examination of the role of nonoperative management in the complete population, the fractures in adults and children have been combined. 
The data includes all inpatients and outpatients treated in the Royal Infirmary of Edinburgh and The Royal Hospital for Sick Children in Edinburgh. These two hospitals provide the only trauma care for a defined population in the East of Scotland. In 2000 the catchment population of the area was 643,702 patients. In the study all patients treated in the catchment area but residing outside were excluded, and all patients who had primary treatment outside the catchment area but were subsequently treated within the area were included. All inpatient and outpatient fractures were included except spinal fractures. As in other centers these are treated by both orthopedic surgeons and neurosurgeons in Edinburgh, with spinal cord injury patients being transferred to a specialized national center outside Edinburgh. 
In this study manipulation under anesthesia was defined as nonoperative management but the soft tissue surgery inherent in the management of open fractures was defined as operative treatment regardless of whether fixation was used. Secondary procedures were not analyzed and the management of pure dislocations and soft tissue damage was not considered. In the study children were defined as being less than 16 years of age, with all patients 16 years and older being defined as adults. The basic demographic details of all patients were included in the database. Fracture location was defined using regional descriptors familiar to all orthopedic surgeons. The OTA classification34 was used to classify all long-bone fractures and the Carstairs and Morris index15 was used to define social deprivation. This index has been used extensively to investigate correlation between disease and social deprivation.27,32 In this study, it was used to test whether social deprivation determined the choice of treatment method in different fractures. Several measures were used to analyze fracture severity and the subsequent decision to use operative treatment. Fracture severity was assessed using the OTA classification34 in metaphyseal and intra-articular fractures of the long bones. OTA type A fractures are extra-articular, type B fractures are partial articular, and type C fractures are complete articular fractures. This system does not apply to proximal humeral, proximal forearm, or proximal femoral fractures, and fracture severity was therefore assessed in fractures of the distal humerus, distal radius, distal femur, proximal tibia, and distal tibia. Nowadays the degree of severity of diaphyseal fractures is often not a major factor in determining management. This is particularly true of lower limb diaphyseal fractures for which intramedullary nailing is now commonly used regardless of the degree of displacement, comminution, or soft tissue damage. 
The type of fracture treatment was also assessed with reference to the mode of injury and the presence of multiple fractures. The seven most common modes of injury were examined to see if particular modes of injury were associated with a higher prevalence of operative treatment. These were motor vehicle accidents, twisting injuries, falls, falls down stairs or slopes, falls from a height, assaults or direct blows, and sporting injuries. The association between operative treatment and the presence of multiple fractures was also examined. 
Table 6-1 shows that, in adults, 67.6% of fractures were nonoperatively managed in 2000 with 63% of fractures in females and 72.8% of fractures in males being treated nonoperatively. There is a significant difference between upper and lower limb fractures, with 81.7% of upper limb fractures and 46.8% of lower limb fractures being treated nonoperatively. In addition, 84.3% of pelvic fractures were treated nonoperatively but most of these were pubic rami fractures occurring in elderly patients. 
Table 6-1
Number and Prevalence of Surgically Treated Adult Fractures Showing Gender and Regional Differences
Operatively Treated
Total Number Number %
Adult fractures 5,576 1,804 32.4
Males 2,650 720 27.2
Females 2,926 1,084 37.0
Upper limb 3,232 590 18.3
Lower limb 2,255 1,200 53.2
Pelvis 89 14 15.7
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Age is an important predictor of the role of operative fracture treatment, as illustrated in Figure 6-1. To allow for a complete analysis of the relationship between age and the requirement for operative fracture treatment, the children’s data from 2000 has been combined with the adult data. Figure 6-1 shows a gradual increase in operative treatment with age. Only 7.3% of patients younger than 5 years were treated operatively compared with 56.9% of patients aged 95 years or more. At about 80 years the prevalence of operative management overtakes nonoperative management and the highest prevalence of operative management is seen between 90 and 94 years of age when 67.4% of patients were treated operatively. Analysis of the equivalent results for males and females shows that both sexes have a similar distribution to the overall distribution shown in Figure 6-1
Figure 6-1
The prevalence of operatively and nonoperatively treated fractures according to patient age.
 
The children’s fracture data has been included and all patients have been divided into 5-year age bands.
The children’s fracture data has been included and all patients have been divided into 5-year age bands.
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Figure 6-1
The prevalence of operatively and nonoperatively treated fractures according to patient age.
The children’s fracture data has been included and all patients have been divided into 5-year age bands.
The children’s fracture data has been included and all patients have been divided into 5-year age bands.
View Original | Slide (.ppt)
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Figures 6-2A and B shows the equivalent age-related curves for upper and lower limb fractures. These are very different from Figure 6-1 and from each other. In the upper limb (Fig. 6-2A) there is a progressive increase in surgery from 9.1% in patients aged less than 5 years to 27.9% in patients aged 70 to 75 years. Older patients show a gradual reduction in surgical treatment. In the lower limb (Fig. 6-2B) there was no surgery undertaken in patients less than 5 years old but in older patients there was a gradual increase in operative treatment up to 95.1% in patients aged 95 years or more. The prevalence of lower limb operative surgery overtakes nonoperative treatment between 65 and 70 years of age. Analysis of the gender-specific curves for upper and lower limb fractures shows no difference to the overall distribution curves shown in Figure 6-2
Figure 6-2
The prevalence of operatively and nonoperatively treated upper limb (A) and lower limb (B) fractures according to patient age.
 
Patients are divided into 5-year age bands. The children’s data has been added to the adult data.
Patients are divided into 5-year age bands. The children’s data has been added to the adult data.
View Original | Slide (.ppt)
Figure 6-2
The prevalence of operatively and nonoperatively treated upper limb (A) and lower limb (B) fractures according to patient age.
Patients are divided into 5-year age bands. The children’s data has been added to the adult data.
Patients are divided into 5-year age bands. The children’s data has been added to the adult data.
View Original | Slide (.ppt)
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When considering fracture treatment nowadays it is important to look carefully at the elderly. There has been an increase in the incidence of osteoporotic fractures23,48 as well as an appreciation that many fractures that formerly occurred in younger patients now commonly occur in the elderly.21 Figure 6-3A shows the prevalence of operative treatment in adults aged 80 years or more, and it can be seen that there is a gradual increase in the use of surgery to treat fractures in this group up to about 93 years of age, when the use of surgical management begins to decline. Figures 6-3B and C shows the relationship between old age and surgery in upper and lower limb fractures. In the upper limb, Figure 6-3B shows that 25% to 35% of adults in their early eighties who present with upper limb fractures are treated surgically, but the prevalence declines to the extent that only 7.4% of upper limb fractures in patients aged 95 years or more were treated surgically. The situation is very different in lower limb fractures, and Figure 6-3C shows that the operative treatment of lower limb fractures gradually increases in the ninth and tenth decades of life. 
Figure 6-3
 
A: Prevalence of operative surgery in adults aged 80 years or more. B, C: Equivalent graphs for upper limb (B) and lower limb (C) fractures.
A: Prevalence of operative surgery in adults aged 80 years or more. B, C: Equivalent graphs for upper limb (B) and lower limb (C) fractures.
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Figure 6-3
A: Prevalence of operative surgery in adults aged 80 years or more. B, C: Equivalent graphs for upper limb (B) and lower limb (C) fractures.
A: Prevalence of operative surgery in adults aged 80 years or more. B, C: Equivalent graphs for upper limb (B) and lower limb (C) fractures.
View Original | Slide (.ppt)
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Table 6-2 shows the prevalence of nonoperative management in different fractures. It indicates that virtually all proximal femoral, femoral diaphyseal, and tibial diaphyseal fractures are now treated operatively, with a very high prevalence of surgery in forearm diaphyseal fractures. There is a very low prevalence of surgery in proximal humeral, proximal radial, clavicular, metatarsal, and toe phalangeal fractures, and in this study no scapular surgery was undertaken—although obviously it is sometimes required. In the remaining fractures shown in Table 6-2, the prevalence of operative treatment varies between 11% and 71%, suggesting that both operative and nonoperative treatments are commonly used. In all fractures the surgeon clearly has to decide whether to treat the fracture operatively or nonoperatively based on many objective and subjective criteria, including the location and severity of the fracture and any associated soft tissue damage; the age and medical condition of the patient; the ability to cooperate with a postoperative treatment regime; and any social habits such as smoking, drinking, and drug taking. Tables 6-1 and 6-2 both show that more surgical intervention is undertaken in lower limb fractures than in upper limb fractures. Table 6-2 also shows the five fractures for which multivariate analysis showed that age was an independent predictor of fracture management. In three fractures—those of the tibial diaphysis, humeral diaphysis, and the pelvis—increasing age was associated with the use of nonoperative treatment but for fractures of the proximal ulna and the distal radius increasing age predicted surgical management. 
Table 6-2
The Prevalence of Operatively Treated Fractures in Adults in Decreasing Order
Fractures Average Age
Treated Operatively
Total n % Surgery Nonop p
Proximal femur 693 676 97.5 80.4 79.7 Ns
Femoral diaphysis 54 51 94.4 67.9 89.0 Ns
Tibial diaphysis 102 96 94.1 42.0 62.7 0.022
Radius/ulna diaphyses 10 9 90.0 33.5 16.0 Ns
Radial diaphysis 11 9 81.2 46.2 54.5 Ns
Distal tibia 35 25 71.4 43.6 44.9 Ns
Proximal tibia 70 48 68.6 48.1 52.1 Ns
Proximal ulna 59 36 61.0 65.4 49.3 <0.001
Distal femur 23 14 60.9 61.7 65.0 Ns
Proximal radius/ulna 12 7 58.3 60.3 64.8 Ns
Talus 15 8 53.3 31.2 34.1 Ns
Distal humerus 28 14 50.0 60.5 61.1 Ns
Ankle 517 206 39.8 48.0 46.9 Ns
Humeral diaphysis 66 24 36.4 45.6 63.0 <0.001
Patella 56 20 35.7 55.1 58.5 Ns
Calcaneus 72 25 34.7 43.5 39.2 Ns
Ulnar diaphysis 38 12 31.6 32.2 43.0 Ns
Midfoot 27 8 29.6 48.0 46.9 Ns
Distal radius 977 285 29.2 61.8 56.9 <0.001
Pelvis 89 14 15.7 56.1 73.2 <0.001
Carpus 151 18 15.7 26.7 34.9 Ns
Finger phalanges 516 59 11.4 37.7 38.9 Ns
Metacarpus 626 69 11.0 28.8 32.1 Ns
Proximal humerus 336 25 7.4 61.5 65.0 Ns
Proximal radius 223 14 6.3 44.4 41.5 Ns
Clavicle 162 9 5.6 42.0 43.2 Ns
Metatarsus 381 15 3.9 42.0 44.4 Ns
Toe phalanges 209 8 3.8 37.6 35.8 Ns
Scapula 17 0
Sesamoid 1 0
 

The average age of patients treated operatively and nonoperatively is shown as is the probability of the age differences being significant.

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Empirically it seems clear that there must be a relationship between the prevalence of operative surgery and the severity of the fracture that has been treated. It is quite difficult to define such a relationship in diaphyseal fractures, as Table 6-2 shows that most diaphyseal fractures tend to be treated operatively now regardless of how serious they are. This does not apply to isolated fractures of the ulnar diaphysis or to humeral diaphyseal fractures but femoral, tibial, and other forearm diaphyseal fractures are now usually treated by internal fixation. On the other hand, an analysis of the severity of the five metaphyseal or intra-articular fractures classified by the OTA34 shows that fracture severity is an independent predictor of surgery (Table 6-3). The only fracture that does not appear to show such a relationship is the distal femoral fracture and many of the patients that present with this fracture are very elderly and frail. It is also interesting to note that ankle fractures show a relationship between fracture severity and the requirement for operative treatment, although the classification basis is different from the fractures listed in Table 6-3. In the 517 ankle fractures shown in Table 6-2, 12.3% of the OTA type A ankle fractures were operatively treated compared with 49.1% of type B fractures and 70% of type C fractures. 
Table 6-3
Prevalence of Surgical Treatment in Different Severities of Metaphyseal and Intra-articular Fractures
OTA Fracture Type
Type A Extra-articular % Type B Partial Articular % Type C Complete Articular % p
Distal humerus 15.4 88.9 66.7 0.002
Distal radius 28.0 10.7 51.8 <0.001
Distal femur 58.3 66.7 62.5 ns
Proximal tibia 18.2 78.0 77.8 <0.001
Distal tibia 30.0 76.9 100.0 0.001
 

The probability of increasing fracture complexity being a predictive factor for surgical treatment is shown.

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An analysis of the role of surgery in the treatment of patients who present with multiple fractures shows that 42.1% of fractures that occur in adults who present with multiple fractures were treated surgically. Statistical analysis showed that the presence of more than one fracture was an independent predictor of surgery in fractures of the midfoot, distal radius, and metatarsus. Table 6-4 shows the prevalence of surgical treatment for the seven most common modes of injury for those fractures in which multivariate analysis showed that the mode of injury was an independent predictor of surgical treatment. The seven modes of injury shown in Table 6-4 accounted for 93.4% of adult fractures. As one might expect, the highest prevalence of surgical fracture treatment is often, but not exclusively, related to motor vehicle accidents. Ankle fractures following falls were more commonly treated operatively than ankle fractures that occurred as a result of motor vehicle accidents, but further analysis showed a higher prevalence of OTA Type C fractures in the older population who sustained an ankle fracture as a result of a fall. The only fracture in which social deprivation independently determined treatment was the metacarpal. These fractures often occur in socially deprived male adolescents and in the Edinburgh study 46.3% followed a fight or an assault. As in many centers, these fractures were most frequently treated nonoperatively. 
Table 6-4
Prevalence of Surgical Treatment in Different Modes of Injury and the Probability of a Statistical Association
Twist Fall Fall Stairs Fall Height Assault/Direct Blow Sport MVA p
Adults
Proximal humerus 5.1 22.2 25.0 25.0 7.1 10.5 0.01
Humeral diaphysis 23.1 60.0 50.0 100 100 0.003
Distal radius 0 28.2 39.4 32.0 11.1 21.9 56.1 0.001
Metacarpus 5.2 0 15.3 11.7 15.8 21.7 0.035
Distal tibia 0 66.6 50.0 88.9 0 100 100 0.005
Ankle 22.4 52.8 33.3 36.4 52.2 48.9 38.1 <0.001
Midfoot 0 0 37.5 0 66.0 100 0.003
Metatarsus 1.3 3.1 3.2 4.3 11.1 0 16.6 <0.001
Children
Clavicle 0 0 0 0 0 10.0 0.011
Proximal radius 0 3.6 9.1 100 0 0 0.015
Proximal ulna 0 100 0 0.012
Distal radius 0 5.4 0 18.3 0 15.7 4.2 <0.001
Finger phalanges 50.0 0 0 0 0 4.6 0 <0.001
 

If the fracture is not listed there was no correlation between fracture treatment and mode of injury.

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Many surgeons will probably be surprised that in 2000 67.6% of fractures were treated nonoperatively in a major trauma unit. One assumes that the prevalence of nonoperative management is declining, and almost certainly this is the case, but this study indicates that in fact nonoperative management is still the most common overall treatment method for fractures in general. However, the overall figure of 67.6% disguises the overall trends. Figures 6-2 and 6-3 show a difference between upper and lower limb fractures, particularly in the elderly. It would be interesting to know if the prevalence of surgery in different fractures is changing in response to a changing population and to improved treatment methods. 
There is very little data by which the changing prevalence can be assessed. There has been no previous complete epidemiologic study in adults but in a remarkable paper Emmet and Breck31 working in El Paso, Texas, before, during, and after World War II analyzed about 11,000 fresh fractures. They combined their pediatric and adult fractures and detailed the management of different fractures. The epidemiology of their population was different from the Edinburgh population, but they analyzed a very large number of fractures and it is interesting to compare their results between 1937 and 1955 with the Edinburgh results in 2000. To permit this the data from the pediatric fractures that were treated in Edinburgh in 2000 have been combined with the adult data. 
Emmet and Breck categorized their fractures differently from the fractures listed in Table 6-2. They combined all of their tibial fractures, except for ankle fractures, and they also combined talar, calcaneal, and midfoot fractures as tarsal fractures. They separated forearm fractures into radius and ulna fractures as well as isolated radius and ulna fractures but they combined proximal and diaphyseal forearm fractures together. Using Emmet and Breck’s fracture criteria the comparative data between 1937 and 1955 and 2000 are shown in Tables 6-5 and 6-6
Table 6-5
Comparison of Edinburgh Data with Emmet and Breck, Fractures with an Increased Prevalence of Surgery in 2000
Emmett and Breck21 Edinburgh
1937–1945 (%) 1946–1950 (%) 1951–1955 (%) 2000 (%)
Humeral diaphysis 22.2 10.6 20.8 33.3
Distal humerus 8.5 17.8 25.3 32.9
Radius and ulna 6.0 13.6 14.9 26.4
Ulna 20.7 17.7 19.8 38.3
Distal radius 6.0 4.2 4.6 20.3
Carpus 0 4.9 7.3 10.1
Proximal femur 47.1 72.3 73.3 97.4
Femoral diaphysis 27.5 41.8 52.1 76.1
Distal femur 50.0 26.1 36.0 65.5
Tibia and fibula 27.5 22.9 30.4 61.8
Ankle 13.0 20.4 22.5 35.8
Tarsus 4.3 5.9 17.4 35.2
 

The Edinburgh data have been adjusted to correspond with Emmet and Breck’s fracture definitions. See text for details.

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Table 6-6
Comparison of Edinburgh Data with Emmet and Breck, Detailing the Fractures without an Increased Prevalence of Surgery in 2000
Emmett and Breck21 Edinburgh
1937–1945 (%) 1946–1950 (%) 1951–1955 (%) 2000 (%)
Clavicle 1.7 2.8 8.7 3.0
Scapula 0 0 3.0 0
Proximal humerus 2.9 7.9 9.6 6.9
Radius 5.5 8.8 10.6 10.4
Metacarpus 7.9 15.7 16.6 9.2
Finger phalanges 13.5 13.6 20.9 7.5
Patella 35.3 38.3 32.1 32.8
Metatarsus 0 6.2 8.5 3.6
Toe phalanges 0 8.4 7.6 3.2
Pelvis 0 22.2 18.2 15.7
Total (Tables 6-56-6) 12.2 17.1 21.6 25.4
 

The Edinburgh data have been adjusted to correspond with Emmet and Breck’s fracture definitions. See text for details.

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Table 6-5 shows those fractures in which there is an increased prevalence of surgery in 2000 and Table 6-6 shows those fractures for which there is no evidence that we now operate more frequently than surgeons in the early 1950s. Table 6-5 indicates that we operate on many more diaphyseal fractures than in the early 1950s. The only exception appears to be the isolated radial fracture (Table 6-6). It must be remembered that proximal radial fractures have been combined with radial diaphyseal fractures and if one looks at Table 6-2 it is obvious that we now operate on many more diaphyseal fractures than were operated on in the 1950s. Table 6-5 also shows that we operate on four or five times the amount of distal radial fractures and this difference is undoubtedly greater if adults alone are examined. 
It is probably more instructive to examine Table 6-6 and see which fractures we do not operate on any more frequently than in the 1950s. It would seem that we in fact treat fewer hand fractures nonoperatively, and this is presumably because of the beneficial effects of industrial legislation, which has significantly decreased the incidence of crushed hand injuries in many countries. However, in some parts of the world serious hand injuries are still relatively common and operative treatment will be more common. 
One should consider that, with the possible exception of toe and patella fractures, surgeons now have access to better implants and techniques than surgeons in the 1950s. It is therefore interesting that the treatment of fractures of the clavicle and proximal humerus in particular seem to be much the same as 50 or 60 years ago. There are now studies suggesting that more of these fractures may be treated surgically in the future, but only time will tell if this occurs.14,62 Many clavicle fractures have a relatively simple morphology and the early results of locked plating of proximal humeral fractures have not been as encouraging as was hoped67 (see Chapter 20). Therefore, it seems likely that nonoperative management of the fractures listed in Table 6-6 will continue to be a popular treatment method. The fractures in Table 6-6 comprise 46.2% of all the fractures treated in Edinburgh in 2000 and this explains the relatively low overall operation rate for this year. The demographic characteristics of nonoperative fracture treatment are summarized in Table 6-7
 
Table 6-7
Essential Demographics of Nonoperative Management
View Large
Table 6-7
Essential Demographics of Nonoperative Management
Prevalence of Nonoperative Management (%)
All Adults (>16 yrs) Adults (>80 yrs)
Overall 67.6 59.5
Males 72.8 68.3
Females 63.0 57.9
Upper limb 81.7 78.4
Lower limb 46.8 12.2
Fractures Most Commonly Treated
Nonoperatively (>90%) Operatively (>70%)
Scapula Proximal femur
Toe phalanges Femoral diaphysis
Metatarsus Tibial diaphysis
Clavicle Radius and ulnar diaphyses
Proximal radius Radial diaphysis
Proximal humerus Distal tibia
Factors Affecting Decision to Operate
Age
Severity of fracture (metaphyseal and intra-articular fractures)
Multiple fractures
Mode of injury (some fractures)
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Techniques of Nonoperative Management

Currently, we tend to use nonoperative techniques to treat stable fractures rather than to facilitate the reduction and stabilization of unstable fractures. It tends to be used to treat undisplaced or minimally displaced fractures or in patients who are elderly, frail, or who have significant medical or social comorbidities. However, in parts of the world with less access to operative fixation techniques, it remains an important treatment method for all fractures, and it is therefore important that surgeons understand the rationale behind the use of all nonoperative techniques. 
There have been several advances in nonoperative fracture management in the last 20 to 30 years, although the basic tenets of management remain unchanged. The use of plaster of Paris casts remains widespread as they are inexpensive and easy to apply. However, fiberglass casts are now more frequently used as they are lighter and more radiolucent. In addition, plastic orthoses, braces, and splints are now more frequently used. Their design has improved but their overall function remains unchanged. 

Traction

The initial argument regarding the role of internal fixation of fractures after World War II centered on femoral diaphyseal fractures. Intramedullary nailing gradually grew more popular and essentially superseded traction as the treatment of choice for femoral fractures in the 1970s and 1980s, but traction is still used in parts of the world and surgeons should understand the rationale behind its use and complications. In addition to the treatment of femoral diaphyseal fractures, traction was used to treat acetabular fractures and fracture dislocations of the hip as well as comminuted fractures of the tibial diaphysis and distal tibia, although its role in the management of these fractures is now extremely limited and essentially confined to situations when internal and external fixation techniques are unavailable. It is still used for the acute management of cervical spine fractures. 
There are six basic methods of skeletal traction that are shown in Figure 6-4. Most traction methods rely on a splint on which the leg is placed. The proximal end or ring of the splint is placed in the patient’s groin and traction is applied by placing a transosseous pin through the distal femur or proximal tibia. Fixed traction is undertaken when the pin is secured to the distal end of the splint by traction cords. In balanced traction the splint is suspended by a pulley system and a second pulley system is applied to the transosseous pin. Traction, using a variable weight, then alters the fracture position with countertraction being achieved by placing the patient head down and raising the end of the bed. Once traction is established the fracture alignment is checked radiologically and pads inserted appropriately to push the femur into correct alignment. A posterior pad under the distal femur is almost always required because of the posterior sag produced by the effect of gravity. 
Figure 6-4
Six methods of skeletal traction.
 
See text for explanation.
See text for explanation.
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Figure 6-4
Six methods of skeletal traction.
See text for explanation.
See text for explanation.
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Many types of traction have been described but the six basic types are shown in Figure 6-4. The first of these is a Thomas splint with a Pearson knee piece attached to the splint (Fig. 6-4A). The Thomas splint supports the leg and balanced traction is applied. After 4 to 6 weeks the knee piece is applied and knee mobilization commenced. This was a commonly used traction apparatus. 
A second type of traction is Braun traction and a weight and pulley system (Fig. 6-4B). This is a very simple traction system that permits traction in the longitudinal axis of the femur. Control of the femoral fragments was difficult. The system, using skin rather than skeletal traction, is still used for temporary traction prior to femoral diaphyseal surgery. 
Another type of traction is Hamilton-Russell traction, which uses a one-pulley system to provide support for the femur and to apply traction (Fig. 6-4C). The mechanical advantage offered by two pulleys at the foot of the bed theoretically meant that the longitudinal pull was twice as great as the upward pull and the resulting traction was at an axis of 30 degrees to the horizontal, approximately in line with the femur. This method of traction does not adequately control the femoral fragments and it was sometimes used after a period of skeletal traction. 
A fourth type of traction is Perkins traction (Fig. 6-4D). This is essentially a straight pull along the axis of the femur through a proximal pin but without a splint. The control of femoral alignment was poor and malunion was common. Perkins believed in early knee mobilization and advocated the use of a split bed later in the treatment of femoral diaphyseal fractures. In this system the patients sat on a bed with the knee flexed over the mattress and knee movement was encouraged while longitudinal traction was maintained. 
A fifth variety of traction is Fisk traction (Fig. 6-4E). This consists of a short Thomas splint and a hinged knee piece. Traction in the axis of the femur was maintained using a proximal tibial transosseous pin but the patient could flex the hip and knee by pulling on a separate cord attached to the end of the thigh splint. 
Finally, there is 90-90 traction (Fig. 6-4F). In this method, the thigh is pulled upward and both hip and knee are at 90 degrees. The advantage of this method is that gravity does not cause posterior sag of the femoral fragments. It was used for proximal femoral diaphyseal fractures when the proximal femoral fracture was flexed by the unopposed action of iliopsoas. The method is still used for pediatric femoral fractures. 
Treatment of femoral diaphyseal fractures by traction should be reserved for cases for which no other method is available. There is considerable morbidity associated with its use. The main complications are failure to maintain normal femoral alignment and significant knee stiffness. Charnley16 documented 34 cases in patients between 20 and 45 years of age with middle and distal third diaphyseal fractures. On average, knee mobilization was commenced at 10 to 25 weeks and the final range of motion was 120 degrees. He also quoted very similar results from Massachusetts General Hospital stating that 44.4% of patients, with an average age of 37 years, had actually regained full knee function. Keep in mind that these were selected series of patients and Charnley’s results were not matched by other surgeons. Connolly et al.17 reported that the use of traction was associated with malunion and nonunion requiring operative treatment in 11% to 29% of cases. Shortening of more than 2 cm occurred in 14% to 30% of cases and refracture in 4% to 17% of cases. They pointed out that the most significant complication was knee stiffness, which occurred in 30% to 50% of cases and affected both elderly and younger patients. In addition to these complications, prolonged traction is associated with significant medical problems and decubitus ulcers. Younger patients also suffered significantly with loss of employment and financial hardship. Psychological problems associated with prolonged bed rest were not uncommon. 
To minimize these complications surgeons turned to the use of a cast brace, which is essentially a long-leg cast with knee hinges to facilitate knee mobilization. This was applied after a few weeks of bed rest but its use was far from problem free. If the surgeon used prolonged bed rest prior to the application of the cast, patients tended to have the problems associated with traction, and if they shortened the period of bed rest it was difficult to apply the cast and mobilize the patient without losing fracture alignment. Using a regime of early application of a cast brace and mobilization, Connolly et al.17 documented a 0.7% prevalence of nonunion and malunion with 13% shortening of more than 2 cm and 5.4% symptomatic loss of knee motion, 2% refracture, and 3% pulmonary emboli. They found the method particularly useful for distal fractures, comminuted mid-diaphyseal fractures, and open fractures. Hardy42 used a similar regime and quoted femoral malalignment in 72.2% of patients, significant knee disfunction in 7.4%, and knee instability in 35.2% of patients. As with femoral traction, the cast brace has now essentially disappeared and should only be used if surgical treatment is unavailable. 
Tibial traction should not be used. It was used in cases of mid-diaphyseal comminution or if it was considered that a tibial plafond fracture was too complex to be treated surgically. Traction was applied through a transosseous calcaneal pin. Unfortunately, the use of excessive traction has been shown to increase the risk of compartment syndrome88 and even if this complication does not occur, traction is associated with the same complications as femoral fractures, these being malalignment, joint stiffness, and nonunion. There is now no indication for tibial traction unless appropriate internal or external fixation techniques are unavailable. 

Spinal Traction

Cervical Spine

Unlike skeletal traction spinal traction remains popular and is in widespread use for the management of cervical fractures and dislocations. It has been shown to be effective in various cervical fractures. Traction is commonly used to reduce a fracture or dislocation, thereby decompressing the neural elements and providing a degree of spinal stability. Spinal traction is rarely used for definitive management and it is usually changed to a halo-body cast or vest, or the surgeon may opt for later surgical stabilization. There are two principal types of cervical traction. These are cranial tongs, of which the best known are the Gardner-Wells tongs, and halo traction. 
Cranial Tongs.
Cranial tongs consist of a hemicircular frame with two spring-loaded angulated pins (Fig. 6-5) that are placed into the outer table of the skull at points about 1 cm posterior to the external auditory meatus and 1 cm superior to the pinna of each ear. Because this is below the widest diameter of the skull the upward pin angulation means that traction can be applied. Each spring-loaded pin is applied with an insertion torque of 6- to 8-inch pounds, and once the tongs are in position a simple pulley system can be set up with a weight hanging over the end of the frame or bed. Care must be exercised in applying weights in case overdistraction and neural damage occurs. 
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Figure 6-5
The use of cranial tongs to apply traction.
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The weight required to reduce the spine varies with the position of the fracture, the degree of ligamentous damage, and the size of the patient. As a rule the surgeon should start with an initial weight of 10 pounds. Approximately 5 pounds per spinal segment are required to reduce the fracture in most patients, although this is only a guide. Thus a load of about 40 pounds will be required for a C5 to C6 injury although the exact weight varies and serial imaging is required to check the position as the load is increased. It is important to obtain a lateral radiograph or fluoroscopic image to visualize fracture reduction. 
Halo Rings.
Closed or open halo rings are now a more popular choice for cervical traction (Fig. 6-6) because they can tolerate higher loading than cranial tongs and can be incorporated into a cast or brace to allow definitive treatment. The halo is attached with four pins: two anterior and two posterior. The pins should be inserted below the widest diameter of the skull with two anterior pins being placed through stab incisions under local anesthetic about 1 cm above the lateral third of the orbital rim. In this location they are lateral to the supraorbital and supratrochlear nerves. The posterior pins are placed about 1 cm above the helix of the ear and to prevent skin necrosis they should not make contact with the ear. Opposing pins should be tightened at the same time to avoid pin displacement, with the pins then being retightened 24 to 48 hours after the initial application. If a pin loosens it can be retightened once to 8-inch pounds. 
Figure 6-6
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Figure 6-6
A halo ring.
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Halo-body Fixation.
The original halo-body device was a body cast attached to a halo. It was devised by Perry and Nickel.70 Halo casts may still be useful if the appropriate bracing materials are not available or if the patient is uncooperative, but nowadays the halo is usually attached to a vest or orthosis (Fig. 6-7), which is made of plastic and tightened with buckles or straps. It is attached to the halo by two anterior and two posterior rods and it is worn until union occurs or a cervical brace is used. 
Figure 6-7
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Figure 6-7
A halo vest.
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Complications.
As with skeletal traction, cervical traction is associated with several complications. It has been estimated that up to 31% of normal cervical spinal motion is permitted by halo-body orthoses and about 10% of patients lose fracture reduction.53 Thus serial radiographs are essential during treatment. As with external skeletal fixation, pin track sepsis is a problem with it occurring in up to 20% of patients. As the fixation is unicortical, pin loosening is also a problem and rates of 36% to 60% have been recorded.35,60 Nerve damage, dural puncture, skull perforation, and brain abscesses have all been reported, and when halo-body fixation is used in quadriplegic patients there is a high incidence of pressure sores, decubitus ulcers, and respiratory complications.35,60 Dysphagia has also been reported. 

Thoracolumbar Spine

Traction is not used for the definitive management of thoracolumbar fractures although prolonged bed rest is still used despite an increasing prevalence of surgical stabilization. Prolonged immobilization necessitates the use of a rotating bed, such as a Stryker bed, which is designed to facilitate skin care, physiotherapy, and personal hygiene. Complications include respiratory problems and decubitus ulcers, and intensive nursing is required. In less-severe thoracolumbar fractures the surgeon may opt for a short period of bed rest followed by surgical stabilization or the use of a thoracolumbar brace or orthosis. 
The use of a short period of thoracolumbar traction is sometimes used as a method of reducing thoracolumbar and lumbar burst fractures prior to the application of a thoracolumbar cast.97 This technique involves the use of a Cotrel frame for a few days to facilitate fracture reduction. At this time, this technique is not in widespread use. 

Casts

Unlike skeletal traction, casts remain popular for fracture treatment and probably remain the most common method of fracture treatment throughout the world. Figures 6-2 and 6-3 and Table 6-2 show that casts are more commonly used to treat upper limb fractures but Table 6-2 also indicates that many less-severe lower limb fractures continue to be treated with casts. Nowadays casts are less commonly used to control the position of a diaphyseal fracture after closed reduction but in some metaphyseal and intra-articular fractures, such as distal radial fractures and ankle fractures, this method of treatment is still widely used. Casts are often used for pain management and to facilitate mobilization in less-severe fractures. The decision between cast management and surgery is frequently subjective and influenced by the patient’s age, physical condition, mental status, and degree of prefracture mobility. In decades to come, it is likely that this decision will become more difficult as the age of the patients increases and they get progressively less fit. 
There are three principles that apply to the treatment of unstable fractures with a cast. 
  1.  
    Utilization of intact soft tissues
  2.  
    Three-point fixation
  3.  
    Hydrostatic pressure
These are illustrated in Figure 6-8 with reference to a fracture of the tibia and fibula. In theory there will often be a hinge of intact soft tissue on one side of the fracture, which can be used to assist with fracture reduction. If three-point fixation is applied through the cast the fracture will be maintained in a reduced position. This theory is somewhat naive, although it may well work in the OTA A3.3 tibial fracture illustrated in Figure 6-8. However, many tibial fractures are not transverse, and obviously the theoretical concept of a soft tissue hinge will be less applicable in spiral, butterfly, segmental, or comminuted fractures. In addition, there may well be soft tissue stripping from the diaphysis adjacent to the fracture and the fracture ends may overlap, which makes reduction more difficult. The last point to bear in mind is that while the soft tissue hinge may be intact in low-velocity fractures in younger patients, it is unlikely to be intact after high-energy injury or in older patients. The periosteum becomes thinner with increasing age and is more easily damaged. As many fractures occur in older patients, the fracture reduction concepts promoted by Charnley16 and others are less applicable. This is illustrated in Figure 6-9. It shows the theoretical use of the soft tissue hinge in a metaphyseal distal radial fracture compared with the more common distal radial fracture in an older person, which is associated with metaphyseal comminution and a poor or absent soft tissue hinge. 
Figure 6-8
 
A: An OTA A3.3 fracture with valgus angulation. B: Three-point fixation, or pressure, will reduce fracture if a soft tissue hinge is present.
A: An OTA A3.3 fracture with valgus angulation. B: Three-point fixation, or pressure, will reduce fracture if a soft tissue hinge is present.
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Figure 6-8
A: An OTA A3.3 fracture with valgus angulation. B: Three-point fixation, or pressure, will reduce fracture if a soft tissue hinge is present.
A: An OTA A3.3 fracture with valgus angulation. B: Three-point fixation, or pressure, will reduce fracture if a soft tissue hinge is present.
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Figure 6-9
 
A: The use of an intact soft tissue hinge and three-point fixation in a distal radial fracture in a young patient. B: The same situation in an older patient with poor soft tissues and bone comminution.
A: The use of an intact soft tissue hinge and three-point fixation in a distal radial fracture in a young patient. B: The same situation in an older patient with poor soft tissues and bone comminution.
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Figure 6-9
A: The use of an intact soft tissue hinge and three-point fixation in a distal radial fracture in a young patient. B: The same situation in an older patient with poor soft tissues and bone comminution.
A: The use of an intact soft tissue hinge and three-point fixation in a distal radial fracture in a young patient. B: The same situation in an older patient with poor soft tissues and bone comminution.
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The principle of hydrostatic pressure is illustrated in Figure 6-10. Hydrostatic pressure relies on the fact that the soft tissues and the diaphysis of the bone are not compressible. Thus, when they are encased in a complete cast or brace they essentially become rigid and maintain the position of the fracture. As with the soft tissue hinge, the explanation is somewhat simplistic and does not take into account active muscle contraction around the fracture. 
Figure 6-10
See text for explanation.
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Figure 6-10
The principle of hydrostatic pressure in cast use.
See text for explanation.
See text for explanation.
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Cast Application

All casts are applied in a similar manner no matter whether the traditional plaster of Paris or more modern fiberglass materials are used. Both types of cast material are frequently used as “slabs,” which are often applied to a limb soon after injury to give temporary support. A full cast is rarely applied immediately after injury because of the potential of swelling associated with the injury to lead to compartment syndrome if the limb is encased in a rigid cast. Slabs are applied by using a layer of protective stockinette and layers of synthetic wool padding (Fig. 6-11). A slab of the appropriate length is then cut and, after soaking, applied to the limb. The location of the slab depends on the fracture. In the lower limb, backslabs or dorsal slabs are usually used, these being applied to the posterior leg and calf to support the fracture until a full cast can be applied or surgery is undertaken. In the upper limb, humeral diaphyseal fractures are often supported with a laterally located slab, fractures around the elbow and forearm being supported with a posteriorly located backslab, and distal radial and carpal fractures with a dorsal slab. 
Figure 6-11
A forearm back slab used to treat an undisplaced distal radial fracture.
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Full casts are applied by wrapping plaster of Paris or fiberglass bandages around the limb after stockinette and synthetic wool have been applied (Fig. 6-12). Up to 30 years ago there was considerable debate regarding how much padding should be used, as surgeons recognized that too much padding permitted secondary fracture displacement but too little padding caused skin problems and increased the risk of compartment syndrome. On the other hand, if the cast is being used to control the position of a reduced fracture, excessive padding should be avoided because redisplacement of the fracture may occur. Cast bandages should be applied carefully, keeping the bandages flat to avoid soft tissue damage. As the cast hardens the surgeon should manipulate the fracture, taking care not to indent the cast material, thereby compressing the underlying soft tissue. Care must be taken not to obstruct joint motion or, if a joint is encased by the cast, it should be placed in the correct position. Once the cast has been applied, radiographs should be obtained to confirm the fracture is in an acceptable position. Cast management of unstable fractures is very labor intensive. Follow-up must be assiduous until callus starts to stabilize the fracture, as it is easy to miss secondary fracture displacement. If this occurs, the position of the fracture must be corrected without undue delay as soft tissue contracture occurs fairly quickly and secondary reduction becomes progressively more difficult. If this occurs, it is important that the surgeon knows how to deal with it. 
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Figure 6-12
A fiberglass scaphoid cast.
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In diaphyseal fractures angular malalignment can be corrected by wedging the cast. In this technique (Fig. 6-13) radiographs, or preferably fluoroscopy, are used to identify the fracture site and the cast is cut leaving a hinge of 2 to 3 cm of the cast intact, the location of the hinge depending on the direction of the necessary correction. Thus if the fracture is in valgus a medial hinge is left and a varus force applied to the distal cast to open the window. Once opened, the position is maintained until more cast material can be applied to maintain the reduced position. In years gone by, plaster rooms would keep a jar of wooden dowling to insert into the cast window to maintain the reduced fracture position while the supplementary plaster of Paris dried. Theoretically, rotational deformity is also correctible by cutting the cast. Again a cut is made in the cast at the level of the fracture and the rotation is corrected, but it is easy to lose position and sometimes it is better to remove the cast and reapply it. Surgeons should be aware that it is difficult to maintain the position of an unstable fracture in a cast, and that is why earlier surgeons defined levels of “acceptable” malunion. If the fracture position is not maintained by the cast, consideration should be given to operative treatment. 
Figure 6-13
Wedging a cast to straighten a diaphyseal fracture of the tibia and fibula.
 
A: The fracture is in valgus. The cast is cut at the level of the fracture to leave a medial hinge. B: The fracture is straightened and the gap in the cast kept open while the cast is completed.
A: The fracture is in valgus. The cast is cut at the level of the fracture to leave a medial hinge. B: The fracture is straightened and the gap in the cast kept open while the cast is completed.
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Figure 6-13
Wedging a cast to straighten a diaphyseal fracture of the tibia and fibula.
A: The fracture is in valgus. The cast is cut at the level of the fracture to leave a medial hinge. B: The fracture is straightened and the gap in the cast kept open while the cast is completed.
A: The fracture is in valgus. The cast is cut at the level of the fracture to leave a medial hinge. B: The fracture is straightened and the gap in the cast kept open while the cast is completed.
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Types of Cast

Upper Limb Casts
Long-arm Cast.
The classic long-arm cast with the elbow at 90 degrees and the wrist included in the cast (Fig. 6-14) is less commonly used now because forearm and elbow fractures are often internally fixed, but it is still used for less-severe fractures. The cast is applied from just below the axilla to just proximal to the metacarpophalangeal joints of the digits but leaving the thumb free. The wrist is placed in 30 degrees of dorsiflexion and the elbow in 90 degrees of flexion. In more minor fractures the wrist may not be included and a full-arm cylinder is then applied. 
Figure 6-14
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Figure 6-14
A long-arm cast.
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Hanging Cast or U-slab.
These casts are routinely used to treat humeral diaphyseal fractures in the acute phase. The arm is placed over the lower chest with the elbow at 90 degrees. A collar and cuff support can be used to maintain the position. A cast is then applied as shown in Figure 6-15, so that the top of the humeral component of the cast is above the humeral fracture. Gravity is used to regain humeral length and the alignment of the fracture can be theoretically adjusted by altering the length of the cast between the neck and forearm. The shorter the cuff the more varus is applied to the fracture. An alternative to the hanging cast is the U-slab or sugar-tong splint, in which a plaster is placed from just below the axilla on the medial side of the arm down and around the elbow and then upward to just below the shoulder. The slab is then bandaged into position. In proximal humeral fractures the slab can be extended above the shoulder but surgeons should be aware that this will negate any beneficial reduction effects of gravity. These casts are often replaced at 2 to 4 weeks by a functional brace (Fig. 6-23). 
Figure 6-15
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Figure 6-15
A hanging cast.
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Figure 6-23
A humeral brace.
 
The sling length can be altered to change the fracture position.
The sling length can be altered to change the fracture position.
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Figure 6-23
A humeral brace.
The sling length can be altered to change the fracture position.
The sling length can be altered to change the fracture position.
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Colles Cast (Forearm Cast).
The Colles, or forearm cast, is the most widely used upper limb cast and is used for most distal radial and ulnar fractures as well as for some carpal injuries. The cast extends from below the elbow to just proximal to the metacarpal necks of the digits with the thumb left free (Fig. 6-16). The application of the Colles cast is frequently preceded by the use of a dorsal plaster slab, which is replaced by the cast once the swelling has reduced. 
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Figure 6-16
A Colles, or forearm, cast.
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Scaphoid Cast.
The scaphoid cast is commonly used to treat scaphoid fractures and pain in the anatomical snuff box on the radial border of the wrist when radiographs do not confirm the presence of a fracture. The wrist is held in slight dorsiflexion and the thumb is in abduction and slight flexion as if a glass is being held between the index finger and thumb (Fig. 6-17). The cast extends from just below the elbow to just proximal to the metacarpal necks of the digits. On the thumb the cast extends to just proximal to the interphalangeal joint. A modification of the scaphoid cast is the extended scaphoid cast, which may be used for fractures distal to the metacarpophalangeal joint of the thumb. In the extended scaphoid cast the whole thumb is included. 
Figure 6-17
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Figure 6-17
A scaphoid cast.
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Bruner Cast.
The Bruner cast is a variant of the extended scaphoid cast that is cut short to release the wrist joint. It is particularly useful for the treatment of ligamentous injuries of the thumb metacarpophalangeal joint but may be used to treat associated minor avulsion fractures. 
Burkhalter Cast.
This cast is used to treat metacarpal or phalangeal fractures. The wrist is placed in 40 degrees of extension and the metacarpophalangeal joints are placed in 70 to 90 degrees of flexion (Fig. 6-18). The cast relies on the intact dorsal hood of the fingers acting as a tension band or a soft tissue hinge. It is usually applied by placing a slab over the dorsum of the forearm and the hand, with the wrist and fingers in the correct position and then applying a forearm cast to secure the slab. Finger extension is not permitted by the dorsal slab but some flexion is allowed. 
Figure 6-18
A Burkhalter cast.
 
This is a combination of a forearm cast and a dorsal slab.
This is a combination of a forearm cast and a dorsal slab.
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Figure 6-18
A Burkhalter cast.
This is a combination of a forearm cast and a dorsal slab.
This is a combination of a forearm cast and a dorsal slab.
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James Cast.
In this cast the fingers are kept in the “position of function” of the hand. The wrist is maintained at 40 degrees of extension with the metacarpophalangeal joints at 90 degrees and the interphalangeal joints of the fingers at 70 to 90 degrees. In this position the collateral ligaments of the metacarpophalangeal joints and the interphalangeal joints are stretched maximally and thus contractures will not occur (Fig. 6-19). As with the Burkhalter cast, the James cast is in fact a combination of a slab and a cast. Initially a volar slab is applied to the forearm and hand with the joints in the correct position. A forearm cast is then applied. 
Figure 6-19
A James slab.
 
This is volar slab that may be supplemented by a forearm cast.
This is volar slab that may be supplemented by a forearm cast.
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Figure 6-19
A James slab.
This is volar slab that may be supplemented by a forearm cast.
This is volar slab that may be supplemented by a forearm cast.
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Other Upper Limb Casts.
Surgeons used to use shoulder spicas to treat factures around the shoulder girdle. These were mainly used for clavicle or proximal humeral fractures. Sometimes the shoulder was placed at 90 degrees of abduction with the elbow at 90 degrees of flexion and the forearm pronated in the “policeman’s halt position.” These casts are now very rarely used with surgeons favoring operative management for the fractures that they were employed to treat. 
Lower Limb Casts
Below-knee Cast.
This is the most common cast used for lower limb injury including ankle fractures, foot fractures, and soft tissue injuries. It is occasionally used to treat undisplaced lower tibial diaphyseal fractures or minor pilon fractures. The cast is applied from below the level of the fibular neck proximally to the level of the metatarsal heads distally with the ankle at 90 degrees and the foot in the plantigrade position (Fig. 6-20). The below-knee cast may be applied as a first stage in a long-leg cast used to treat an unstable tibial diaphyseal fracture. 
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Figure 6-20
A below-knee cast.
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Long-leg Cast.
Surgeons usually use a long-leg cast to treat unstable tibial diaphyseal fracture in the acute phase changing to a patellar tendon-bearing cast after a few weeks. They may also be used to treat fractures around the knee. A long-leg cast is best constituted by applying a below-knee cast and then flexing the knee to about 10 degrees, following which the thigh extension is applied (Fig. 6-21). 
Figure 6-21
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Figure 6-21
A long-leg cast.
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Patellar Tendon-bearing Cast.
The other variant of the below-knee cast is the patellar tendon-bearing cast, which is usually used to treat tibial diaphyseal fractures after a few weeks in a long-leg cast. In this cast the proximal end of a below-knee cast is extended upward as far as the lower pole in the patella and moulded around the patellar tendon to provide a degree of rotational stability (Fig. 6-22). Care must be taken not to apply pressure over the common peroneal nerve running around the neck of the fibula. 
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Figure 6-22
A patella tendon-bearing cast.
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Spinal Casts.
Spinal casts are now rarely used. The basic cast is a plaster jacket that extends from the sternal notch to the symphysis pubis and is carefully moulded. If fractures lower than L3 are to be treated, the cast should be extended downward to include one thigh. If cervical fractures are treated in a cast, the cast is extended upward into a collar but the use of cervical casts is now extremely unusual and they would only be used if no other treatment method was available. Thoracolumbar casts are still used by some surgeons,97 but the results are no better than those associated with spinal braces. 

Braces

Limb Braces

Many different limb braces have been designed but they fall into four main types used to treat fractures of the humeral diaphysis, distal radius, metacarpus, and lower leg. Most braces are made of polyethylene or plastic and secured by Velcro, plastic straps, and buckles. Braces tend to be lighter than casts and are often used after a short period of cast immobilization once the fracture is more stable. Other advantages are that braces can be tightened as the soft tissue swelling decreases and they can be removed for personal hygiene and radiologic evaluation of the fracture. 
Upper Limb
Humeral Brace.
A simple polyethylene or plastic brace is often used to treat humeral diaphyseal fractures after the initial cast management. The brace fits around the arm and is usually wider laterally than medially to support the humerus proximally (Fig. 6-23). 
Distal Forearm Brace.
These are used to treat distal radial fractures and may be used after a period of cast immobilization or they may be applied primarily to the forearm. There are two basic types. Figure 6-24 shows a conventional distal forearm brace, which extends to the radiocarpal joint. Alternatively, the brace may have a dorsal extension to just proximal to the metacarpophalangeal joints of all digits except the thumb. 
Figure 6-24
A distal forearm brace.
 
A modification of this brace includes an extension to just proximal to the MCPJs, except the thumb.
A modification of this brace includes an extension to just proximal to the MCPJs, except the thumb.
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Figure 6-24
A distal forearm brace.
A modification of this brace includes an extension to just proximal to the MCPJs, except the thumb.
A modification of this brace includes an extension to just proximal to the MCPJs, except the thumb.
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Metacarpal Brace.
Metacarpal braces are usually either made up of a strap worn around the hand under which padding is placed to maintain fracture reduction or they take the form of a heat-molded plastic brace which is placed around the hand and then molded into an appropriate shape to maintain fracture reduction (Fig. 6-25). They can be used for the primary treatment of metacarpal fractures40 or to protect the metacarpus after operative fracture treatment.55 Skin necrosis has been reported.36 
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Figure 6-25
A metacarpal brace.
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Lower Limb
Below-knee Brace.
The most popular lower limb brace is the equivalent of the below-knee cast. There are many available but all tend to be made of plastic and fasten with Velcro or straps (Fig. 6-26). They are used for the same indications as below-knee casts and may be used after an initial period of cast management. They are commonly used after internal fixation of ankle and foot fractures or to allow mobilization after a soft tissue injury to the ankle, hindfoot, or midfoot. 
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Figure 6-26
A below-knee brace.
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Patellar Tendon-bearing Brace.
This is the equivalent of the tendon-bearing cast but it permits ankle movement (Fig. 6-27). The plastic brace is fitted with an ankle hinge and a heel cup and can therefore be worn inside a shoe. 
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Figure 6-27
A patella tendon-bearing brace.
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Knee Brace.
This is the modern equivalent of the old cast brace but it is no longer used to treat femoral diaphyseal fractures. Now it is made from synthetic material and fitted with adjustable integral knee hinges (Fig. 6-28). These are often used to treat soft tissue injuries around the knee but may be used to facilitate mobilization after internal fixation of distal femoral or proximal tibial fractures. In some minor fractures around the knee they may be used for definitive treatment. 
Figure 6-28
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Figure 6-28
A knee brace.
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Spinal Braces

Cervical Braces.
There are three types of cervical braces: Soft and hard collars, high cervicothoracic orthoses, and low cervicothoracic orthoses (Fig. 6-29A). Within these three types there are many different designs but they all have the same basic function. Standard soft and hard collars are not generally used for the treatment of acute cervical fractures or dislocations but they are useful for the treatment of minor soft tissue sprains and whiplash injuries. They allow up to 80% of normal cervical movement and therefore confer little stability to the cervical spine.49,60 Their main function is to act as a proprioceptive stimulus to remind patients to take care. Rigid cervical collars may be used for emergency stabilization of the injured cervical spine but the most effective way of stabilizing the cervical spine is by strapping the chin and forehead to a rigid spinal board. 
Figure 6-29
Different types of cervical braces.
 
A: A cervical collar. B: A high cervicothoracic orthosis. C: A low cervicothoracic orthosis.
A: A cervical collar. B: A high cervicothoracic orthosis. C: A low cervicothoracic orthosis.
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Figure 6-29
Different types of cervical braces.
A: A cervical collar. B: A high cervicothoracic orthosis. C: A low cervicothoracic orthosis.
A: A cervical collar. B: A high cervicothoracic orthosis. C: A low cervicothoracic orthosis.
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High cervicothoracic orthoses (Fig. 6-29B) have molded occipitomandibular supports that extend to the upper part of the thorax. The best-known example of this orthosis is the Philadelphia collar. Studies indicate that the Philadelphia collar resists 71% of normal cervical flexion and extension, 34% of lateral bending, and 54% of rotation.60 Other similar orthoses show similar results. These types of braces are useful for the management of cervical sprains or to provide temporary immobilization during transport or after surgical stabilization of the cervical spine. 
Low cervicothoracic orthoses have the same molded upper support but extend to the lower part of the thorax (Fig. 6-29C). Examples of these braces are the Minerva and SOMI (sternal–occipital–mandibular immobilizer) braces. Low cervicothoracic orthoses are better than high cervicothoracic orthoses in resisting cervical rotation and sagittal movement in the mid and lower cervical spine but they do not prevent all cervical movement. If any type of neck brace is used to treat an unstable or potentially unstable cervical fracture serial radiographs must be taken to check that fracture reduction is maintained until union. 
The complications of cervical braces are essentially the same as those associated with limb braces. As cervical movement is not prevented, loss of fracture reduction may occur in unstable fractures. In addition, a poorly fitting brace may be uncomfortable and cause skin and soft tissue irritation and damage.60 
Thoracic and Lumbar Braces.
The role of thoracolumbar braces is to support the spine by limiting overall trunk motion, decreasing muscular activity, increasing the intra-abdominal pressure, resisting spinal loading, and limiting spinal motion. Several braces are available; the simplest is a lumbosacral corset and the most complex is an individually moulded thoracolumbar–sacral orthosis made from plastic and tightened by buckles and straps (Fig. 6-30). A useful intermediate brace is the Jewett brace (Fig. 6-31), which provides three-point fixation and permits spinal extension but not flexion. 
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Figure 6-30
A thoracolumbarsacral orthosis.
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Figure 6-31
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Figure 6-31
A Jewett brace.
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Lumbar corsets, like cervical collars, are essentially proprioceptive and serve to remind the patient to take care. They are used in the management of low back pain but their only use in spinal injury is in the management of minor stable fractures or soft tissue injury. The Jewett brace is useful in the treatment of injuries between T6 and L3, which are unstable in flexion. Studies have shown that it reduces intersegmental motion and flexion at the thoracolumbar joint while lateral bending and axial rotation remain unaffected.9 They are more effective in the treatment of one- and two-column spinal fractures than in the treatment of three-column fractures. Thoracolumbar–sacral orthoses provide more stability but maintenance of reduction of unstable thoracolumbar fractures cannot be guaranteed and serial radiographs are required to confirm the maintenance of fracture reduction. 

Casts or Braces?

There has been a lot of debate whether casts or braces are more useful and which gives better results. The debate is mainly centered on tibial diaphyseal fractures, distal radial fractures, and ankle fractures. In ankle fractures the debate has mainly concerned the management of internally fixed fractures in the postoperative phase, whereas in the other fractures surgeons have compared the use of casts and braces in nonoperatively managed patients. 

Tibial Diaphyseal Fractures

The comparative usefulness of casts and braces in the treatment of tibial diaphyseal fractures was a subject of considerable debate until about 20 years ago, when intramedullary nailing became the treatment of choice for these fractures. The implication in the literature is that functional bracing produced better results, with Sarmiento and colleagues being particular proponents of functional bracing.8082 Table 6-8 shows a comparison of the results of tibial fractures treated with long-leg casts, patellar tendon-bearing casts, and functional bracing. It shows the results of the major papers published between 1965 and 1992, when patellar tendon-bearing casts and functional braces were popular. It must be remembered that the importance of functional outcome following tibial diaphyseal fracture became more widely recognized during this period, and several earlier papers extolled the virtues of their chosen method without analyzing functional outcome to any significant degree. 
Table 6-8
Comparison of Use of Long-leg Casts, Patellar Tendon-bearing Casts, and Functional Braces
No. Open (%) Union (wks) Malunion (%) Joint Stiffness (%)
Long-leg Casts
Nicoll63 674 22.5 15.9 8.6 25.0
Slatis and Rokkanen90 198 33.3 19.8 ? ?
Karaharju et al.51 80 23.7 ? 11.2 27.5
Steen Jensen et al.91 102 ? ? 21.0 7.0
Van der Linden and Larsson100 50 12.0 17.0 50.0 24.0
Haines et al.38 91 36.3 16.3 25.3 33.0
Kay et al.52 79 22.8 19.1 9.1 ?
Kyrö et al.56 165 21.0 13.7 30.0 42.0
Patellar Tendon-bearing Casts
Sarmiento80 69 0 13.6 ? ?
Austin4 132 11.4 16.7 39.0 ?
Bostmann and Hanninen10 114 16.0 15.3 40.0 ?
Puno et al.73 141 17.0 16.7 4.4 ?
Oni et al.66 100 0 ? 21.0 43.0
Hooper et al.46 33 21.0 18.3 27.3 15.0
Bone et al.8 25 0 26.0 27.0 Yes
Functional Braces
Sarmiento80 135 24.4 15.5 ? ?
Sarmiento81 780 31.0 18.7 13.7 ?
Digby et al.25 82 20.7 17.4 9.0 45.0
Den Outer et al.24 94 11.7 ? 40.0 ?
Pun et al.72 97 7.2 17.1 23.7 28.9
Alho et al.1 35 31.4 17.0 8.6 26.0
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The papers shown in Table 6-8 that discuss the use of long-leg casts confirm that the method is associated with significant knee stiffness, particularly if used for complex fractures, open fractures, or in fractures that were associated with nonunion. Few modern surgeons would treat open tibial diaphyseal fractures with a long-leg cast but it is interesting to note that Nicoll63 reported 60% delayed or nonunion in open tibial fractures managed in a long-leg cast in 1965. He also reported 25% joint stiffness rising to 70% in tibial nonunions associated with an open fracture. The results of the use of long-leg casts were reported as late as 1991, when Kyrö et al.56 analyzed the use of long-leg casts in 165 consecutive tibial fractures. Traction was used in severe open fractures and a calcaneal pin was incorporated into the cast of 23% of the patients. They found that 26% of patients had impaired knee flexion and 9% had impaired knee extension. In addition, 42% had impaired ankle flexion and 37% had impaired toe movement. Only 21% of the patients thought that they had an excellent result. The other papers listed in Table 6-8 show the significant problems of malunion and joint stiffness associated with the use of long-leg casts. 
There is no doubt that the use of patellar tendon-bearing casts and functional braces facilitated knee mobilization but it should be remembered that during the period when these methods of management were introduced surgeons had turned to operative treatment for open and more severe closed fractures, and thus the results presented in Table 6-8 for patellar tendon-bearing casts and functional braces may well have been achieved in more straightforward fractures than those treated by long-leg casts in earlier years. However, comparison of the results of tendon-bearing casts with long-leg casts shows a similar prevalence of malunion and probably joint stiffness. Functional braces were introduced to facilitate hindfoot mobility but again one must remember that the patients analyzed in these studies almost certainly had more benign fractures than those treated previously in long-leg casts. Sarmiento et al.82 analyzed 780 patients treated with a functional brace but selected ambulatory patients and excluded fractures with excessive initial shortening and those that showed an increasing angular deformity in the initial cast. Their results were good but they did not assess malunion or joint stiffness. Table 6-8 shows that other studies have found significant levels of malunion and joint stiffness. Digby et al.25 reviewed 103 adult tibial fractures and reported that 11% had restricted ankle motion and 45% had reduced subtalar function. These results match those of the other papers listed in Table 6-8, and it is salutary to observe that a comparison of the three methods of casting and bracing does not show that functional bracing gives superior results, although long-leg casts are associated with greater knee stiffness. 

Distal Radial Fractures

Stewart et al.92 undertook a prospective study comparing a conventional Colles cast with an above-elbow cast brace and a below-elbow cast brace in the treatment of displaced distal radial fractures. In both the above-elbow and below-elbow cast brace they used a dorsal extension of the brace beyond the wrist joint, which extended as far as the metacarpophalangeal joints of the fingers. The brace only extended to the carpometacarpal joint of the thumb. The authors undertook a radiographic and functional analysis of the patients and found no statistical difference in either the radiographic or functional results between the three different methods of management. They also noted no difference in the prevalence of complications between the three groups of patients. They did comment that there was better patient tolerance of casts than braces with the main problem of bracing being pressure over the distal radial border and the head of the ulna. They felt that in most patients there was no reason to change from the traditional Colles cast. 
In a later study, Tumia et al.99 compared the traditional Colles cast with a forearm functional brace that did not have an extension beyond the wrist joint (Fig. 6-24). They treated both minimally displaced fractures, which did not require manipulation, and displaced fractures which did require manipulation. The results were assessed using a functional and anatomical scoring system. They found that the brace-treated patients had lower functional scores than the cast-treated group at 12 weeks, but the difference was not statistically significant. By 24 weeks the results were similar. Grip strength was initially higher in both manipulated and nonmanipulated brace-treated groups, but by 12 weeks there was no difference with cast-managed fractures. There was also more pain associated with the brace during the first 5 weeks, but this settled later. Their conclusion was that a brace could be used effectively in treating Colles fractures. In a similar study O’Connor et al.65 compared a plastic cast with a lightweight removable splint in 66 patients with minimally displaced radial fractures. They also used both anatomical and functional evaluation systems and found no significant differences between the two groups, but patients tended to prefer the brace. 

Ankle Fractures

There have been several studies comparing the use of casts and braces after operative management of ankle fractures. Tropp and Norlin98 compared the use of a plaster cast for 6 weeks with an ankle brace applied 1 to 2 weeks after surgery. They permitted early weight bearing in both groups and showed that by 10 weeks there was improved function in the brace-managed group. This had disappeared by 12 months but they did report impaired dorsiflexion in the cast group, compared with the functional brace group. 
DiStasio et al.26 examined a group of U.S. military personnel with operatively treated ankle fractures. They compared the use of a nonweight-bearing cast for 6 weeks with the use of a nonweight-bearing removable orthosis, and showed that the orthosis group had better subjective scores for pain, function, cosmesis, and motion 3 and 6 months after injury, but there was no difference in objective assessment of function on return to duty. Simanski et al.89 compared the use of a functional brace with early weight bearing with a standard cast without weight bearing after ankle fixation. Both groups did well and most of the patients achieved their preinjury level of activity. The authors of both these studies stated that braces were useful but emphasized the requirement of reliable, cooperative patients! In a prospective randomized study Lehtonen et al.57 compared the use of a below-knee cast and a functional brace in Weber type A and B fractures treated operatively. There were no significant differences between the study groups in the final subjective and objective evaluations, but there were more wound complications in the brace-managed group. In all studies dealing with casts or braces in operatively managed ankle fractures, differences in outcome have been shown to be relatively minor. 
The comparative results of the use of casts or braces in tibial diaphyseal fractures, distal radial fractures, and ankle fractures indicate that there is no advantage of either method. The studies suggest return of joint movement is slightly faster if a brace is used but there is no evidence that overall function is better with a brace. There is also some evidence that early complications are higher if a brace is used. The choice between a brace and a cast is determined by the surgeon and patient. Braces are obviously useful. Personal hygiene is easier, and physical therapy, if indicated, can be more easily undertaken, but braces are also more expensive and are not freely available in all countries. The decision should be based on these factors but also on the reliability of the patient. Casts have a great advantage in that they are difficult, although not impossible, to remove and are therefore advantageous in the treatment of many young males in particular! 

Slings, Bandages, and Support Strapping

Several types of minor injuries, soft tissue sprains, and minor fractures are treated by support and analgesia with mobilization of the affected area encouraged after a relatively short period. Tubular elastic support bandages are frequently used to treat minor soft tissue injuries such as ankle and foot sprains, wrist sprains, or minor ligament damage in other joints. Several upper limb fractures are treated by the use of slings, which may be supplemented by bandaging. 
Fractures of the clavicle, proximal humerus, and radial head and neck are often treated by sling support until the discomfort settles enough to allow joint movement. Several different methods of bandaging have been used to treat clavicle fractures in an effort to reduce pain and maintain fracture reduction. The figure-of-eight bandage remains popular in the treatment of clavicle fractures. This is placed anteriorly around both shoulders and crossed over at the level of the upper thoracic spine. Theoretically, tightening the bandage reduces and stabilizes the fracture, but unfortunately it loosens quickly and clinical evidence suggests that it is no better than a sling.3 Fractures of the clavicle, proximal humerus, and proximal radius that are treated nonoperatively are best treated by the use of a sling for 2 weeks followed by mobilization of the affected joint. 
Another area for which strapping is useful is in the management of stable undisplaced fractures of the phalanges of the hand and foot. These fractures can be treated by buddy strapping the affected digit to an adjacent digit (Fig. 6-32). Usually two strips of half-inch tape are placed around the proximal and middle phalanges with protective gauze between the fingers. The joints should be left free to permit mobilization. It should be remembered that this type of strapping loosens quickly and the patient, or companion, should be taught how to replace it. 
Figure 6-32
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Figure 6-32
Buddy strapping.
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The use of an elastoplast thumb spica (Fig. 6-33) may be helpful in treating sprains or minor tears of the collateral ligaments of the thumb. It can also be used for treating minor-associated avulsion fractures. These are constructed of elastoplast tape, which is placed around the thumb and extends down to the carpometacarpal area. As with buddy strapping, they tend to loosen quickly and need to be replaced. Neither buddy strapping nor elastoplast spicas should be used to treat unstable fractures. 
Figure 6-33
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Figure 6-33
A thumb spica.
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Splints

Many different splints have been designed, usually for the treatment of metacarpal and phalangeal fractures. The two most popular splints are the aluminium foam-backed splint (Fig. 6-34) and the mallet finger splint (Fig. 6-35). Aluminium foam-backed splint are used for phalangeal fractures. They are commonly applied to the volar or dorsal aspects of the digits to immobilize fractures or joints after reduction of a dislocation. They are also useful for immobilizing the finger after soft tissue injuries, and a volar splint may be particularly helpful for maintaining extension after a volar plate injury. In more unstable fractures the surgeon may elect to use an aluminium foam-backed splint in the same way as a Burkhalter (Fig. 6-18) or James (Fig. 6-19) cast might be used. This is appropriate for a single digit fracture and the splint is extended across the wrist joint maintaining the position of the wrist as described for the Burkhalter or James splint. 
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Figure 6-34
An aluminium foam-backed splint.
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Figure 6-35
A mallet finger splint.
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Mallet fingers caused by either avulsion of the extensor tendons from the distal phalanx or by a fracture of the distal phalanx are well treated by the use of a Mallet finger splint (Fig. 6-35). An appropriately sized splint is applied to the digit with the distal interphalangeal joint in full extension. If this method of management is used the patient is taught that the distal interphalangeal joint must be kept extended for a period of 6 weeks. The main problem with the technique is failure of the patient to follow the treatment protocol, with the splint being removed too early. 

Specific Fractures

Upper Limb

Suggested guidelines for the nonoperative management of upper limb fractures are shown in Table 6-9
Table 6-9
Guidelines for Nonoperative Management for Different Upper Limb Fractures if Nonoperative Management is Chosen as the Treatment Method
Fracture Type Nonoperative Management
Scapula Sling and mobilize at 2 wks
Clavicle Sling and mobilize at 2 wks
Proximal humerus Sling and mobilize at 2 wks
Humeral diaphysis Hanging U-slab or sugar-tong cast. Brace at 2–3 wks
Distal humerus Long-arm cast for 4–8 wks
Olecranon Long-arm cast for 6 wks
Proximal radius Sling and mobilize at 2 wks
Forearm diaphysis
 Both bones (undisplaced) Long-arm cast. Forearm cast at 4 wks
 Radius only Forearm cast 6 wks
 Ulna only Forearm cast 6 wks
 Distal radius and ulna Forearm cast or brace for 6 wks
Scaphoid Scaphoid cast for 6–12 wks
Other carpal bones Forearm cast for 3–6 wks
Metacarpal fractures
 Undisplaced Mobilize
 Displaced Burkhalter or James splint. Mobilize at 3 wks
Phalangeal fractures
Proximal and middle phalanges
 Undisplaced Buddy strapping and mobilize
 Displaced Burkhalter, James, or aluminium splint. Mobilize at 3 wks
 Distal phalanx Mobilize or mallet splint
 

See relevant chapters for suggested management for different fractures.

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Shoulder Girdle

Clavicle.
The management of clavicular fractures is described in detail in Chapter 38. Historically most clavicle fractures have been managed nonoperatively (Fig. 6-36A) and Table 6-2 shows that this continues to be the case. However in recent years there has been considerable interest in primary internal fixation of clavicle fractures, with both plating and intramedullary pinning being used.14,37,64 Not surprisingly, opinion continues to be divided regarding the best method of treatment. Nordqvist et al.64 analyzed 225 consecutive clavicle fractures treated nonoperatively and showed that 185 were symptomatic, 39 had moderate pain, and 1 patient had a poor result. There were seven nonunions in displaced fractures. They advocated nonoperative management as did Grassi et al.,37 who compared nonoperative treatment and intramedullary pinning in 80 clavicle fractures. They found no difference in the outcome scores between the two groups. 
Figure 6-36
 
A: A clavicular fracture with a two large intermediate fragments but little shortening. There is debate about whether operative or nonoperative treatment is appropriate for these fractures, but in this case union and good function was successfully achieved with nonoperative management. B: A Neer Type I distal clavicle fracture which was treated nonoperatively. Good function was achieved.
A: A clavicular fracture with a two large intermediate fragments but little shortening. There is debate about whether operative or nonoperative treatment is appropriate for these fractures, but in this case union and good function was successfully achieved with nonoperative management. B: A Neer Type I distal clavicle fracture which was treated nonoperatively. Good function was achieved.
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Figure 6-36
A: A clavicular fracture with a two large intermediate fragments but little shortening. There is debate about whether operative or nonoperative treatment is appropriate for these fractures, but in this case union and good function was successfully achieved with nonoperative management. B: A Neer Type I distal clavicle fracture which was treated nonoperatively. Good function was achieved.
A: A clavicular fracture with a two large intermediate fragments but little shortening. There is debate about whether operative or nonoperative treatment is appropriate for these fractures, but in this case union and good function was successfully achieved with nonoperative management. B: A Neer Type I distal clavicle fracture which was treated nonoperatively. Good function was achieved.
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More recently the Canadian Orthopaedic Trauma Society14 pointed out that several studies indicated there was a high prevalence of symptomatic malunion and nonunion after nonoperative management of midshaft clavicle fractures, and they undertook a prospective study comparing plate fixation with nonoperative management in displaced clavicle fractures. They found that the outcome scores were significantly improved in the operatively managed group at all time points and that there was a reduced union time and prevalence of nonunion in the operatively managed fractures. They advocated plate fixation of completely displaced midshaft clavicle fractures in active adult patients. 
It seems likely that more midshaft clavicle fractures will be treated by internal fixation in the future but clearly more work is required to establish the precise indications for operative treatment. As many clavicle fractures are undisplaced or minimally displaced nonoperative management will continue to be an important treatment method and it is important to review the alternative methods of nonoperative management. 
Most surgeons use a sling when treating clavicle fractures nonoperatively. The sling is usually maintained for 2 weeks and then physical therapy is started. The historical alternative to the sling was the figure-of-eight bandage. The rationale behind the use of a figure-of-eight bandage was that the shoulders were extended and fracture reduction thereby facilitated, but comparative studies have shown no advantage of the figure-of-eight bandage over a simple sling. Andersen et al.3 actually found that the sling caused less discomfort and fewer complications. If nonoperative management is used to treat a clavicle fracture, it is suggested that a sling should be worn for about 2 weeks and then a physical therapy regime instituted. 
Approximately 28% of clavicle fractures occur in the distal third of the bone (Fig. 6-36B).76 As with midshaft clavicle fractures, there has been debate about how lateral clavicular fractures should be treated, with interest concentrating on the Neer type 2 distal clavicle fractures associated with transection of the coronoid and trapezoid ligaments. The treatment of the condition will be discussed in detail in Chapter 38, but the literature suggests that nonoperative management is a good alternative for many lateral third clavicle fractures, particularly in middle-aged and elderly patients.76,77 As with mid-diaphyseal clavicle fractures, if nonoperative management is chosen to treat a distal clavicle fracture a sling should be used for 2 weeks and a physical therapy regime then commenced. 
Scapula Fractures.
Scapula fractures are very rare and are predominantly treated nonoperatively. The implication is that they occur in high-energy injuries and they have been documented to occur in 7% of multiple-injured patients.102 However, Chapter 3 shows that they actually have a type A distribution with a proportion of scapula fractures occurring in the elderly and, in general, nonoperative treatment will be used. 
There are four basic types of scapula fractures: Intra-articular and extra-articular glenoid fractures, acromion fractures, coracoid fractures, and fractures of the scapula body (Fig. 6-37). Most scapular fractures do not require operative management, the obvious exception being the displaced glenoid rim fracture associated with instability of the glenohumeral joint. Most coracoid and acromion fractures are undisplaced and few require surgical treatment. In addition, there is little evidence that scapular body fractures need operative treatment, with a meta-analysis of scapula fractures showing that 99% of body fractures were treated nonoperatively.106 The same study also showed that the literature indicates that 83% of scapula neck fractures are treated nonoperatively.106 Van Noort and van Kampen101 examined 13 patients with scapula neck fractures and found an average Constant score18 of 90 after nonoperative management with no correlation between functional outcome and malunion. Pace et al.68 confirmed the good outcome associated with nonoperative management but pointed out that most patients had some activity-related pain and minor cuff tendinopathy which, they thought, related to glenoid neck malunion. 
Figure 6-37
A fracture of the scapular body and neck in a 52-year-old male.
 
Nonoperative management was used and the patient had a good result although he had some pain at the extremes of shoulder movement.
Nonoperative management was used and the patient had a good result although he had some pain at the extremes of shoulder movement.
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Figure 6-37
A fracture of the scapular body and neck in a 52-year-old male.
Nonoperative management was used and the patient had a good result although he had some pain at the extremes of shoulder movement.
Nonoperative management was used and the patient had a good result although he had some pain at the extremes of shoulder movement.
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It is likely that most scapula fractures will continue to be treated nonoperatively and if this method of treatment is chosen, it is suggested a sling is used for about 2 weeks to provide pain relief, following which a physical therapy program should be instituted. Scapular fractures are discussed in detail in Chapter 39
Floating Shoulder.
The term “floating shoulder” is given to a combination of clavicle and scapular neck fractures. It was initially felt that clavicle stabilization would minimize scapular neck malunion44 but later papers suggest that nonoperative treatment of the floating shoulder gives equivalent or better results. Egol et al.29 compared operative and nonoperative management and showed no significant difference between the two methods. They did note that internal and external rotation was weaker in the operatively treated group although there was improved forward flexion in this group. Edwards et al.28 reported similar results but stressed that more severely displaced fractures were associated with poorer results. Thus the literature suggests that most floating shoulders should be treated nonoperatively using a sling for 2 weeks followed by a course of physical therapy. 

Proximal Humeral Fractures

Most proximal humeral fractures are treated nonoperatively (Fig. 6-38) and a comparison with the prevalence of surgery in the 1950s (Table 6-6) suggests that there was little change for a considerable period. The recent introduction of locking plates has increased the rate of surgical treatment but this must be balanced against the increasing age and infirmity of the elderly population who tend to present with this fracture. It seems logical to assume that most proximal humeral fractures will continue to be treated nonoperatively for the foreseeable future. The overall management of this fracture is discussed in Chapter 37
Figure 6-38
A three-part valgus impacted (OTA B1.1) proximal humeral fracture presenting in a 78-year-old female.
 
This united and at 1 year the Neer score was 84 and the Constant score was 74.
This united and at 1 year the Neer score was 84 and the Constant score was 74.
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Figure 6-38
A three-part valgus impacted (OTA B1.1) proximal humeral fracture presenting in a 78-year-old female.
This united and at 1 year the Neer score was 84 and the Constant score was 74.
This united and at 1 year the Neer score was 84 and the Constant score was 74.
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The debate about the treatment of proximal humeral fractures is centered around three- and four-part fractures and fracture dislocations, which comprise about 12.5% of proximal humeral fractures.20 Neer61 stated that 85% of proximal humeral fractures were minimally displaced fractures, although a more recent study showed that 49% of proximal humeral fractures were minimally displaced.19 The difference probably relates to the increased incidence of osteopenic and osteoporotic fractures in the population since Neer’s study. These fractures should be managed nonoperatively. There is debate about the management of two-part fractures, particularly with the introduction of the locking proximal humeral plate, but these plates have only been partially successful67 and it seems likely that many two-part fractures will continue to be managed nonoperatively. If further information about the results of nonoperative treatment of two-part proximal humeral fractures and fracture dislocations is required, the 1-year Neer61 and Constant18 scores of all two-part fractures classified according to the OTA classification has been published.22 Figure 6-38 shows an impacted valgus three-part B1.1 fracture in a 78-year-old female who had a good result with nonoperative management. 
Nonoperative management is undertaken by placing the patient in a sling for 2 weeks and then gradually introducing a program of physical therapy. The patient should be warned that progress is slow and that it is often more than 1 year before maximum shoulder motion is regained. 

Humeral Diaphyseal Fractures

Table 6-2 shows that together with isolated ulnar diaphyseal fractures, humeral diaphyseal fractures are the only diaphyseal fractures that are now commonly treated nonoperatively. Table 6-2 also shows that there is a significant age difference between the patients treated operatively and those treated nonoperatively, with younger patients tending to be treated operatively. About two-thirds of patients with humeral diaphyseal fractures are treated nonoperatively (Fig. 6-39) and this figure is supported by an analysis of the literature. In 1988, Zagorski et al.105 reported on the use of a functional brace in humeral diaphyseal fracture. They analyzed 170 patients and showed that 167 had excellent or good functional results. Since then, further studies30,33,47,74,78,96 have accepted that nonoperative management gives good results but they have tried to analyze which fractures, if any, are better treated surgically. Clearly open fractures, irreducible fractures, pathologic fractures, fractures in the multiply injured, and floating elbows may well be treated surgically, but Ekholm et al.30 also noted that OTA type A fractures seemed to have a high prevalence of nonunion and often required revision surgery. Ring et al.74 took a similar view stating that spiral or oblique fractures that involved the middle or proximal third had a high rate of nonunion after treatment with a functional brace. Toivanen et al.96 treated 93 consecutive fractures with a brace but found that 23% required surgery. Again they found a higher rate of nonunion in proximal third diaphyseal fractures. 
Figure 6-39
AP and lateral radiographs of an OTA B2.1 humeral diaphyseal fracture in a 68-year-old patient.
 
The fracture extends into the proximal humerus. It was treated by the application of a U-slab followed by a brace and union occurred.
The fracture extends into the proximal humerus. It was treated by the application of a U-slab followed by a brace and union occurred.
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Figure 6-39
AP and lateral radiographs of an OTA B2.1 humeral diaphyseal fracture in a 68-year-old patient.
The fracture extends into the proximal humerus. It was treated by the application of a U-slab followed by a brace and union occurred.
The fracture extends into the proximal humerus. It was treated by the application of a U-slab followed by a brace and union occurred.
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The other disadvantage of nonoperative management that has been highlighted recently is impairment of shoulder function. Fjalestad et al.33 reported that 38% of patients treated with a humeral brace lost external rotation of the shoulder, which they attributed to malrotation at the fracture site. Rosenberg and Soudry78 analyzed 15 patients treated by bracing and showed that the Constant shoulder scores were significantly lower in the injured shoulder. The average age was only 43 years and only 40% of the patients returned to their previous professional activities. 
There has been a particular interest in bracing fractures of the distal third of the humeral diaphysis. Fracture alignment can be difficult to maintain and there is concern about elbow stiffness.47 Sarmiento et al.83 analyzed 85 distal third fractures, of which 15% were open. They recorded 96% union with no infections. In a recent study Jawa et al.47 compared operative and nonoperative management and found very similar results between them, although they stated that operative treatment gives more predictable alignment and potentially a quicker return of function, although there was as risk of nerve damage and infection. 
It seems likely that the prevalence of surgical treatment of humeral diaphyseal fractures will increase. As studies have become more refined it is becoming apparent that there are advantages to surgery in some fractures. Nonoperative management will probably continue to be an important method of management for reducible middle third closed fractures but other fracture types will probably be treated operatively more frequently than they are now. If nonoperative management is selected, it is suggested that a U-slab or sugar-tong cast is used for about 2 weeks and a functional brace then applied. The brace is usually used for 8 to 12 weeks with serial radiographs used to determine union. Active elbow motion is usually allowed by about 4 weeks. The treatment of humeral diaphyseal fractures is discussed in Chapter 36

Distal Humeral Fractures

It is perhaps surprising to see that Table 6-2 shows that only 50% of distal humeral fractures were treated nonoperatively in a major trauma center in a 1-year period. However, Table 6-3 shows there is a considerable difference in surgery based on the OTA classification. A review of the OTA Type A extra-articular distal humeral fractures shows that nonoperative management was mainly reserved for undisplaced or minimally displaced epicondylar fractures or supracondylar fractures in the elderly (Fig. 6-40). Most OTA Type B and C fractures were treated operatively. The average age of the patients with Type C fractures who were treated nonoperatively was 92 years! Thus most displaced distal humeral fractures are treated operatively. 
Figure 6-40
AP and lateral radiographs of an OTA A2.3 undisplaced supracondylar humeral fracture in an 89-year-old patient.
 
Union occurred with nonoperative management but there is a high rate of nonunion in displaced supracondylar fractures.
Union occurred with nonoperative management but there is a high rate of nonunion in displaced supracondylar fractures.
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Figure 6-40
AP and lateral radiographs of an OTA A2.3 undisplaced supracondylar humeral fracture in an 89-year-old patient.
Union occurred with nonoperative management but there is a high rate of nonunion in displaced supracondylar fractures.
Union occurred with nonoperative management but there is a high rate of nonunion in displaced supracondylar fractures.
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There is little literature dealing with type A extra-articular distal humeral fractures. A1 fractures affecting the epicondyle tend to occur in younger patients and A2 and A3 supracondylar fractures tend to occur in the elderly. There is debate about whether these should be managed nonoperatively as there is a relatively high rate of nonunion. However it is likely that undisplaced Type A distal humeral fractures will continue to be treated nonoperatively. If nonoperative management is used for A1 fractures, a long-arm cast should be used for 4 to 6 weeks. If an A2 or A3 fracture is treated in the elderly the cast may need to be worn for up to 8 weeks. Distal humeral fractures are discussed in Chapter 35

Proximal Forearm Fractures

Proximal Radial Fractures.
Table 6-2 shows that most radial head and neck fractures continue to be treated nonoperatively, and a review of Table 6-6 suggests that the treatment has changed little for many years. The 6.3% primary surgery listed in Table 6-2 related mainly to complex fracture dislocations of the elbow and the relatively uncommon OTA C2 and C3 fractures. Most surgeons accept that most proximal radial fractures should be treated nonoperatively. If nonoperative management is used, all that is required is a sling with joint movement being started as soon as pain permits. 
Olecranon Fractures.
Table 6-2 shows that most olecranon fractures are treated by internal fixation. It also shows that those fractures treated nonoperatively tended to occur in younger patients. Nonoperative treatment is usually used for undisplaced fractures or if there is only a minor avulsion fracture from the tip of the olecranon. If nonoperative management is used for a potentially unstable olecranon fracture, a long-arm cast should be applied for 6 weeks following which a physical therapy regime is instituted. If there is a minor avulsion fracture from the tip of the olecranon treatment should be symptomatic and mobilization commenced about 2 weeks after fracture. The treatment of proximal forearm fractures is discussed in Chapter 34

Forearm Fractures

Most forearm fractures are treated by internal fixation as detailed in Chapter 33. Table 6-2 shows that over 80% of isolated radial diaphyseal and 90% of radial and ulna diaphyseal fractures will be treated operatively. The only exceptions are stable undisplaced fractures, which can be treated in a cast or brace. Isolated ulna diaphyseal fractures are frequently treated nonoperatively, with Table 6-2 indicating that about 30% are treated operatively. Many isolated ulna diaphyseal fractures are undisplaced or minimally displaced and the use of a cast or brace will give good results. Sarmiento et al.84 reported on 287 ulnar shaft fractures and recorded 99% union. They found that proximal third ulna fractures were associated with an average loss of pronation of 12 degrees but overall there were good or excellent results in 96% of patients. If nonoperative management is used for undisplaced fractures of the radius and ulna, a long-arm cast should be applied, which can be converted to a forearm cast or brace at about 6 weeks if further immobilization is required. For undisplaced isolated fractures of the radius, a forearm cast or brace can be used, usually for 6 weeks, and if isolated ulna fractures are to be treated nonoperatively a forearm cast or brace can be applied for 6 weeks. 

Distal Radial Fractures

Table 6-2 shows that about 70% of distal radial fractures are treated nonoperatively (Fig. 6-41) and Table 6-5 shows that there has been an increase in operative management over the years. There is an increased appreciation of the importance of fracture reduction and carpal alignment and progressively more distal radial fractures are being treated operatively. The introduction of locked plates and different types of external fixation has altered the management of these fractures but a substantial proportion of distal radial fractures are stable and will continue to be managed nonoperatively. As with other osteopenic and osteoporotic fractures the epidemiology of distal radial fractures will change significantly in a rapidly aging population, who will present with more medical comorbidities. As a result of changing patient demographics it may well be that more distal radial fractures will be treated nonoperatively in the future. Distal radial fracture treatment is discussed in Chapter 32
Figure 6-41
 
A: AP and lateral radiographs of a distal radial fracture in a frail 70-year-old female. Note the presence of dorsal and volar comminution. B: Closed manipulation was undertaken and AP and lateral radiographs at 6 weeks show that good alignment has been maintained although there is some radial shortening. Good function was achieved.
A: AP and lateral radiographs of a distal radial fracture in a frail 70-year-old female. Note the presence of dorsal and volar comminution. B: Closed manipulation was undertaken and AP and lateral radiographs at 6 weeks show that good alignment has been maintained although there is some radial shortening. Good function was achieved.
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Figure 6-41
A: AP and lateral radiographs of a distal radial fracture in a frail 70-year-old female. Note the presence of dorsal and volar comminution. B: Closed manipulation was undertaken and AP and lateral radiographs at 6 weeks show that good alignment has been maintained although there is some radial shortening. Good function was achieved.
A: AP and lateral radiographs of a distal radial fracture in a frail 70-year-old female. Note the presence of dorsal and volar comminution. B: Closed manipulation was undertaken and AP and lateral radiographs at 6 weeks show that good alignment has been maintained although there is some radial shortening. Good function was achieved.
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If a stable distal radial fracture is to be treated nonoperatively, a forearm cast or brace should be applied for 6 weeks, and following removal a physical education program instituted. If an unstable fracture is to be treated nonoperatively, reduction needs to be undertaken using a hematoma block, regional block, or general anesthetic. The classic reduction technique is to apply traction, flexion, and ulnar deviation and to check the fracture position on radiographs or fluoroscopy. If the fracture does not reduce, the Agee maneuver can be used (Fig. 6-42). Once the fracture has been reduced a dorsal slab or short forearm cast is applied. The fracture must be x-rayed 7 to 10 days after the initial reduction to check that the reduction has been maintained. If it has not been maintained, the surgeon must decide on further fracture management based on the age of the patient, his or her functional state, and the presence of medical comorbidities. Remanipulation is generally unsuccessful in older patients, and in most cases of redisplacement the surgeon will have to consider operative treatment, although in very elderly demented patients the fracture will often be left in the malreduced position. If the fracture position is maintained the cast or slab is completed and worn for 6 weeks. Alternatively, a functional brace can be used. Following removal of the cast or brace, a physical therapy regime should be instituted. 
Figure 6-42
The Agee maneuver.
 
This places a volar translation force on the distal radial fragment, which allows the lunate to tilt the distal fragment in a volar direction.
This places a volar translation force on the distal radial fragment, which allows the lunate to tilt the distal fragment in a volar direction.
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Figure 6-42
The Agee maneuver.
This places a volar translation force on the distal radial fragment, which allows the lunate to tilt the distal fragment in a volar direction.
This places a volar translation force on the distal radial fragment, which allows the lunate to tilt the distal fragment in a volar direction.
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Carpal Fractures

Table 6-2 shows that about 15% of carpal fractures are treated surgically, and Table 6-5 indicates that the prevalence of operative treatment has recently increased. There has been increasing interest in primary scaphoid fixation after fracture and it seems likely that the number of scaphoid fractures treated surgically will increase. However, many scaphoid fractures are stable fractures and it is likely that nonoperative management will continue to be popular. A recent analysis20 showed that scaphoid fractures comprise about 82% of carpal fractures suggesting that nonoperative management for carpal fractures will continue to be used. A further 9% of carpal fractures were triquetral fractures, which are also treated nonoperatively. Complex carpal fractures and dislocations do require surgical treatment but are relatively uncommon. 
If nonoperative management is used a scaphoid cast is applied (Fig. 6-17). It usually needs to be worn for 6 to 8 weeks but union can be slow and the cast may need to be worn for up to 12 weeks. If other carpal fractures are treated a cast or brace is usually worn for 3 to 6 weeks, depending on the type of fracture. Flake fractures of the triquetrum usually require only 3 weeks in a forearm cast. The treatment of carpal fractures is discussed in Chapter 31

Metacarpal Fractures

Metacarpal fractures are very unusual in that it would seem that they are more frequently treated nonoperatively than they were 60 years ago, despite the availability of screws, mini-plates and mini-fixators. Table 6-2 shows than only about 11% of metacarpal fractures had primary operative treatment in 2000 in a major trauma unit. It is likely that the reduction in operative treatment relates to improved industrial and workplace safety legislation in many countries. Crushed hands are much less common than in the post World War II period and an analysis of metacarpal fractures in 2000 shows that they are mainly low-energy fractures with about 50% being caused by a direct blow. About 60% of fractures affect the little finger metacarpal (Fig. 6-43) and 54% of these affect the metacarpal neck.20 
Figure 6-43
A fracture of the neck of the little finger metacarpal.
 
Most of these fractures are treated nonoperatively.
Most of these fractures are treated nonoperatively.
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Figure 6-43
A fracture of the neck of the little finger metacarpal.
Most of these fractures are treated nonoperatively.
Most of these fractures are treated nonoperatively.
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Nonoperative treatment of isolated stable undisplaced or minimally displaced metacarpal fractures usually involves the use of buddy strapping and mobilization, although not infrequently no supportive strapping is actually required at all. If closed reduction is required, it can be achieved by flexing the metacarpophalangeal joint to 90 degrees and using the proximal phalanx to push the metacarpal head dorsally and to control rotation. This is known as the Jahss technique. The indications for fracture reduction mainly relate to angulation, rotation, and shortening and are discussed in Chapter 30. Surgeons may elect to treat malreduced or unstable fractures operatively but if nonoperative management is undertaken a Burkhalter or James type of cast or splint should be used. These are usually maintained for about 3 weeks, following which a physical therapy regime is organized. Fractures of the neck, diaphyses, and bases of metacarpals are similarly treated but basal fractures or fracture dislocations of the thumb metacarpal may well be treated by the application of a Brunner cast, which may be maintained for 4 to 6 weeks. 

Phalangeal Fractures

The prevalence of operative treatment of phalangeal fractures is similar to metacarpal fractures (Table 6-2) and, as with metacarpal fractures, comparison with Emmett and Breck’s data from 60 years ago31 shows that we seem to operate less now. Presumably, as with metacarpal fractures, this is because the incidence of crushed hands and severe hand injuries has declined mainly as a result of improved workplace legislation. As with metacarpal fractures, many phalangeal fractures are stable (Fig. 6.44) and require no more than buddy strapping or the application of an aluminium foam–backed splint to minimize pain and the possibility of secondary displacement. If phalangeal fractures are stable after reduction they can be treated by the application of a Burkhalter- or James-type splint, or by the use of a longer aluminium foam-backed splint bent to maintain the finger in the same position as achieved by the splint. Again the splint will be maintained for 2 to 3 weeks. 
Figure 6-44
A comminuted fracture of the proximal phalanx of the little finger.
 
This was treated with an aluminium foam-backed splint. Good alignment and function was achieved.
This was treated with an aluminium foam-backed splint. Good alignment and function was achieved.
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Figure 6-44
A comminuted fracture of the proximal phalanx of the little finger.
This was treated with an aluminium foam-backed splint. Good alignment and function was achieved.
This was treated with an aluminium foam-backed splint. Good alignment and function was achieved.
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Fractures of the distal phalanges are frequently treated nonoperatively. Tuft fractures and closed diaphyseal fractures tend to be stable and are often treated by local splintage for pain relief. Basal fractures of the distal phalanx are often unstable but can frequently be treated in full extension on a splint for 4 weeks. Bony mallet injuries are treated similarly in a mallet splint. The treatment of phalangeal fractures is discussed in Chapter 30

Lower Limb Fractures

Suggested guidelines for the nonoperative treatment of lower limb fractures are shown in Table 6-10
Table 6-10
Guidelines for Nonoperative Management for Different Lower Limb Fractures if Nonoperative Management is Chosen as the Treatment Method
Fracture Type Nonoperative Management
Pelvis
Insufficiency fracture (elderly patient) Mobilize as pain permits
APC Type 1 and LC Type 1 Mobilize as pain permits
Undisplaced acetabulum (except transtectal type) Mobilize as pain permits
Proximal femur Not recommended
Femoral diaphysis Not recommended
Distal femur (undisplaced) Hinged knee brace for 6–8 wks
Patella (undisplaced) Long-leg cylinder cast or brace. Mobilize at 4–6 wks
Proximal tibia (undisplaced) Hinged knee brace for 6–8 wks
Tibial diaphysis Long-leg cast. Patellar tendon-bearing cast or brace at 4–6 wks
Distal tibia (undisplaced) Lower leg cast or brace for 6–8 wks
Ankle Lower leg cast or brace for 6 wks
Talus Lower leg cast or brace for 6 wks
Calcaneus Lower leg cast or brace for 6 wks
Midfoot Lower leg cast or brace for 4–6 wks
Metatarsus Mobilize or lower leg cast or brace for 4–6 wks
Toes Buddy strapping and mobilize
 

See relevant chapters for suggested management for different fractures.

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Proximal Femoral Fractures

Table 6-2 indicates that proximal femoral fractures are treated operatively unless the patient’s medical condition means that surgery is contraindicated. In undisplaced intracapsular femoral neck fractures, there is a higher prevalence of nonunion, avascular necrosis, and fracture displacement in nonoperatively treated fractures.20 In addition, nonoperative management means that an elderly patient, often with significant medical comorbidities, is confined to bed for 4 to 6 weeks, which is clearly undesirable. The only proximal femoral fracture for which nonoperative management may be the treatment of choice is the greater trochanter fracture, when there may be little or no displacement. Even in these fractures, surgeons should be aware that there may be an intertrochanteric extension. Lesser trochanter fractures are very rare but may be treated nonoperatively. In older patients these fractures should be assumed to be metastatic fractures until proven otherwise. The treatment of proximal femoral fractures is discussed in Chapters 48 to 50

Femoral Diaphyseal Fractures

Femoral diaphyseal fractures should no longer be treated nonoperatively unless the patient is not fit for surgery or the facilities to allow operative treatment are unavailable. The results from nonoperative treatment are significantly inferior to operative management. If nonoperative management is used then one of the methods of traction illustrated in Figure 6-4 should be used. There is probably no other fracture in which there is such a strong consensus in favor of one treatment method, and intramedullary nailing is generally used for all femoral diaphyseal fractures. The management of femoral diaphyseal fractures in discussed in Chapter 52

Distal Femoral Fractures

Table 6-2 shows that most distal femoral fractures are treated operatively, which is what one would expect, although in recent years there has been a significant change in the epidemiology of distal femoral fractures. These fractures now commonly occur in the elderly, with the epidemiologic review in Chapter 3 giving an average age of 55.3 years in males and 69.6 years in females for patients with this fracture. Many of the patients who present with distal femoral fractures have other medical comorbidities. A review of the 39.1% of distal femoral fractures that were treated nonoperatively as detailed in Table 6-2 shows that virtually all were undisplaced fractures in older or clinically unwell patients. Thus, nonoperative management is now mainly used for low-energy undisplaced fractures that usually occur in elderly patients. Nonoperative management will usually involve the application of a long-leg cast for about 4 weeks following which a hinged knee brace can be applied. As fractures treated nonoperatively are usually undisplaced, union may be fairly rapid. This is particularly true for OTA type B partial articular fractures (Fig. 6-45), which are not infrequently undisplaced or minimally displaced. Under these circumstances a cast or brace may well only need to be used for 6 to 8 weeks. The treatment of distal femoral fractures is detailed in Chapter 53
Figure 6-45
AP and lateral radiographs of an OTA B1.1 lateral condylar fracture in an 82-year-old female with significant medical comorbidities who did not mobilize.
It was treated with a long-leg cast.
It was treated with a long-leg cast.
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Patella Fractures

Patella fractures are discussed in Chapter 54. Most occur in older patients as a result of a fall.20 Therefore, undisplaced or minimally displaced patella fractures are relatively common and these are usually treated nonoperatively. Table 6-2 shows that about 35% to 40% of patella fractures are treated operatively, these being the more serious fractures. Nonoperative management usually involves the use of a long-leg cylinder cast or brace, which is worn for about 6 weeks. A physical therapy program is then instituted. 

Proximal Tibial Fractures

Proximal tibial fractures have a somewhat unusual distribution with a bimodal distribution in both males and females (Chapter 3). About 48% of the fractures detailed in Table 6-2 were high-energy injuries that occurred in younger patients, which explains the higher incidence of operative treatment with almost 70% of patients being treated operatively. As with distal femoral fractures, the patients treated nonoperatively tend to present with undisplaced or minimally displaced fractures. If nonoperative management is used for proximal tibial fractures, a hinged knee brace should be applied for 6 to 8 weeks. If this is unavailable a long-leg cylinder cast can be used. The treatment of proximal tibial fractures is discussed in Chapter 55

Tibial Diaphyseal Fractures

The treatment of tibial diaphyseal fractures has changed considerably in the last 20 years. The treatment of these fractures was the subject of much debate until relatively recently. Long-leg casts, patellar tendon-bearing casts and functional braces have all been used to treat both closed and open tibial diaphyseal fractures (Table 6-8) but the results were relatively poor and intramedullary nailing has become the treatment of choice for these fractures. This is discussed in Chapter 57. Table 6-2 shows that about 94% of tibial diaphyseal fractures were treated operatively in Edinburgh, with nonoperative management being mainly reserved for stable OTA A3.1 transverse tibial fractures with an intact fibula that occur mainly in younger patients. These unite quickly and are treated in a below-knee cast. 
If nonoperative management is to be used for an unstable tibial diaphyseal fracture it is recommended that a long-leg cast is applied initially and that a patellar tendon-bearing cast or brace be applied after 4 to 6 weeks. Serial radiographs will be required to determine when union has occurred and, therefore, when to remove the cast. Traction should not be used to stabilize tibial diaphyseal fractures as it is associated with increased intracompartmental pressure and the effects of prolonged bed rest. There is now no indication for traction. If internal fixation cannot be used to treat a tibial diaphyseal fracture, external fixation is usually possible. 

Distal Tibial Fractures

Much of the literature dealing with distal tibial or pilon fractures concerns displaced high-energy fractures occurring in younger patients. These fractures are treated operatively as detailed in Chapter 58. Further analysis of the distal tibial fractures shown in Table 6-2 shows that about 40% of them were OTA type A extra-articular fractures and 31% were OTA type B partial articular fractures. Table 6-3 shows the prevalence of surgery in the different OTA fracture types, and it can be seen that while most type B and all type C fractures are treated operatively only 30% of type A fractures were treated surgically. Of these patients, 47% were 14 to 16 years of age and had physeal fractures, and the remaining 53% had an average age of 59 years and presented mainly with low-energy undisplaced or minimally displaced fractures. Thus, as with other lower limb fractures, there is a distinct difference in fracture treatment based on age, mode of injury, and fracture displacement. If nonoperative management is to be used for an undisplaced or a minimally displaced type A or type B pilon fracture, a nonweight-bearing below-knee cast or brace is adequate and it may need to be worn for 8 to 10 weeks depending on the speed of union. In younger patients with physeal fractures the use of a cast or brace for 4 to 6 weeks is adequate. 

Ankle Fractures

Table 6-2 shows that overall about 40% of ankle fractures are treated operatively. As has already been pointed out, the prevalence of operative treatment of metaphyseal and intra-articular fractures varies with the degree of severity of the fracture as defined by the OTA classification (Table 6-3). This principle also applies to ankle fractures, although their OTA classification is somewhat different from the classifications of the fractures shown in Table 6-3. Further analysis of the ankle fractures shown in Table 6-2 shows that about 12% of type A infrasyndesmotic fractures were treated operatively, these mainly being isolated medial malleolar fractures. This compares with 49% of transsyndesmotic type B fractures and 70% of suprasyndesmotic type C fractures. Thus most type A and about half of type B fractures will be treated nonoperatively. A review of the patients who present with type C fractures but were treated nonoperatively shows that most had external rotation rather than abduction injuries and it was felt that the posterior tibiofibula ligaments were intact. They were considered to be stable after the application of a cast. If this method of management is chosen, serial radiographs must be undertaken to make sure there is no evidence of late syndesmotic widening. 
Analysis of the type B fractures shows that 84.3% of the bimalleolar fractures and 94.3% of the trimalleolar fractures were treated operatively. A review of the lateral malleolar fracture associated with talar shift, the OTA B2.1 fracture, showed that 91.4% of fractures were treated operatively but an analysis of the prevalence of operative management in the common OTA B1.1 spiral lateral malleolar fracture caused by external rotation shows that only 16.8% of these fractures were treated operatively. It is important to realize that B1.1 fractures associated with 2 to 3 mm of displacement do not require operative treatment and that an excellent result can be obtained with cast or brace management (Fig. 6-46).5,54 Care must be taken to be certain that the patient does not actually have an OTA B2.1 fracture with talar shift, and radiographs should be obtained after the application of the cast and at 2 weeks to check for this. If nonoperative ankle fracture treatment is undertaken a below-knee cast or brace is applied for 6 weeks. Many surgeons do not permit weight bearing for 6 weeks after cast application but there is no good evidence to support this regime41 and weight bearing can be allowed in most ankle fractures. Ankle fractures are discussed in Chapter 59
Figure 6-46
 
A: An OTA B1.1 ankle fracture in a 50-year-old female. Note the slight lateral translation of the distal fibula. B: Surgery is not required. Union occurred with good ankle function.
A: An OTA B1.1 ankle fracture in a 50-year-old female. Note the slight lateral translation of the distal fibula. B: Surgery is not required. Union occurred with good ankle function.
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Figure 6-46
A: An OTA B1.1 ankle fracture in a 50-year-old female. Note the slight lateral translation of the distal fibula. B: Surgery is not required. Union occurred with good ankle function.
A: An OTA B1.1 ankle fracture in a 50-year-old female. Note the slight lateral translation of the distal fibula. B: Surgery is not required. Union occurred with good ankle function.
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Talar Fractures

Fractures of the talus are relatively uncommon, but Table 6-2 shows that about 50% are treated operatively. A review of the epidemiology of talar fractures has shown that about 70% are body fractures and 30% are neck fractures.20 Further analysis of the body fractures shows that about 42% are shear or crush injuries but 50% are fractures of the lateral or posterior processes, which are often treated nonoperatively. Undisplaced fractures of the talar body are relatively rare but can be treated nonoperatively (Fig. 6-47). 
Figure 6-47
A lateral radiograph of an undisplaced fracture of the talar body in a 26-year-old male.
 
It was treated in a below-knee cast with a good result being obtained.
It was treated in a below-knee cast with a good result being obtained.
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Figure 6-47
A lateral radiograph of an undisplaced fracture of the talar body in a 26-year-old male.
It was treated in a below-knee cast with a good result being obtained.
It was treated in a below-knee cast with a good result being obtained.
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A review of the talar neck fractures showed that about 30% were Hawkins type I43 fractures, which are also commonly treated nonoperatively. Thus while displaced neck and body fractures will usually be treated operatively, there are several talar fractures that will be managed nonoperatively. If nonoperative management is to be undertaken, the use of a nonweight-bearing below-knee cast or brace for 6 to 8 weeks is recommended. Following its removal a physical therapy regime should be instituted. Talar fractures are discussed in Chapter 60

Calcaneal Fractures

There has been considerable recent discussion about the management of calcaneal fractures.13,71 These are often displaced intra-articular fractures and as such should benefit from operative treatment. There is continued debate about the indications for surgery and many calcaneal fractures continue to be managed nonoperatively.13 Table 6-2 shows that in a trauma unit where fracture fixation of intra-articular calcaneal fractures remains routine about 35% of fractures are treated by primary operative fixation. As with talar fractures, it is important to understand the epidemiology of calcaneal fractures in order to understand why only 35% of fractures are treated operatively. Analysis of the calcaneal fractures included in Table 6-2 shows that about 60% are intra-articular; the remaining 40% are extra-articular calcaneal body fractures or fractures of the anterior, medial, or lateral processes or of the posterior tuberosity.20 Many of these fractures will be treated nonoperatively. Also, an analysis of types of intra-articular calcaneal fracture using the Sanders classification79 shows that about 16% of intra-articular calcaneal fractures are undisplaced Sanders type 1 that do not require surgery (Fig. 6-48). In addition, there are other factors that affect the choice of management in calcaneal fractures. It is assumed that intra-articular calcaneal fractures occur in young patients and many do, but there has been an increasing prevalence of these fractures in older patients, with 12.7% of the calcaneal fractures included in Table 6-2 occurring in patients of at least 65 years of age. Surgeons often treat these patients nonoperatively. 
Figure 6-48
Axial and lateral radiographs of an undisplaced fracture of the calcaneus which does not require surgery.
Rockwood-ch006-image048.png
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If nonoperative treatment is used for calcaneal fractures it is suggested that a nonweight-bearing below-knee cast or brace be used for 6 weeks, and then weight bearing and a physical therapy regime instituted. Calcaneal fractures are discussed in Chapter 61

Midfoot Fractures

Table 6-2 indicates that about 30% of midfoot fractures are treated operatively. A review of the epidemiology of midfoot fractures shows that there are four basic fracture types, these being avulsion fractures, shear fractures, uniarticular impaction fractures, and biarticular impaction fractures.20 About 45% of midfoot fractures are avulsion fractures, which are generally treated nonoperatively. Operative treatment tends to be used mainly for shear fractures or for maintaining the length of the medial and lateral columns of the midfoot in more severe fractures or fracture dislocations. The other indication for operative treatment is if the fracture is associated with a Lisfranc dislocation of the tarsometatarsal joint. Thus, more severe midfoot injuries tend to be treated operatively. If nonoperative treatment is used it is usually for less-severe injuries and the use of a nonweight-bearing cast or brace for 6 weeks is adequate. Midfoot fractures are discussed in Chapter 62

Metatarsal Fractures

Metatarsal fractures are relatively common but Table 6-2 shows that very few are treated operatively. About 90% of metatarsal fractures are isolated injuries, with about 70% to 75% affecting the fifth metatarsal.20 Most are low-energy injuries and are treated nonoperatively (Fig. 6-49). Some multiple metatarsal fractures or fractures associated with significant displacement or with a Lisfranc dislocation of the tarsometatarsal joint require operative treatment but these are frequently associated with high-energy injuries to the foot. Stress fractures of the metatarsal are not uncommon and are also treated nonoperatively. Treatment of metatarsal fractures is essentially symptomatic. No treatment is required if the patient can manage to mobilize without significant discomfort. If the fracture is painful, it is suggested that a below-knee cast or brace be applied for 3 weeks and then reapplied if the pain continues. Mobilization can be allowed when the patient can manage this. Metatarsal fractures are discussed in Chapter 62
These should be managed nonoperatively.
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Figure 6-49
Minimally displaced fractures of the third, fourth and fifth metatarsal necks in a 43-year-old female.
These should be managed nonoperatively.
These should be managed nonoperatively.
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Toe Fractures

Table 6-2 shows that, as with metatarsal fractures, nonoperative treatment of toe fractures is very common. Analysis of the toe phalangeal fractures in Table 6-2 shows that about 20% involved the hallux, and that five of the eight fractures that were treated operatively were in the hallux. Surgical treatment of the other toes is rarely required. If nonoperative management is used, buddy strapping to the adjacent toe is usually all that is needed, although the treatment is usually symptomatic and frequently no treatment is actually required. 

Pelvic and Acetabular Fractures

Table 6-2 shows that the prevalence of operative management of pelvic and acetabular fractures is relatively low. This may be surprising to surgeons working in Level I trauma centers but it must be remembered that most fractures involving the pelvis are insufficiency fractures of the pubic rami and occur in the elderly. In the last 30 years there has been an explosion of interest in the surgical treatment of pelvic and acetabular fractures. The pelvic fractures that occur in younger patients that are still frequently treated nonoperatively are anterior posterior compression type I injuries and the lateral compression104 type I injuries. Treatment is restricted weight bearing depending on the degree of discomfort. Most acetabular fractures are treated operatively with nonoperative management reserved for undisplaced fractures with the exception of transtectal transverse fractures, which may displace later.20 Treatment is restricted weight bearing for 10 to 12 weeks and a physical therapy program. Pelvic and acetabular fractures are discussed in Chapters 46 and 47

Spinal Fractures

Very little is known about the prevalence of nonoperative management of all cervical and thoracolumbar fractures, but it is a very common method of treatment with many of the perceived advantages of spinal fixation not having been proven in clinical trials. The management of spinal fractures is discussed in detail in Chapters 43 to and 45

Specific Fracture Types

Periprosthetic Fractures

Increasing longevity, with associated osteopenia and osteoporosis, together with an increased use of arthroplasty and fracture fixation have lead to a rapid increase in the incidence of periprosthetic fractures. These usually occur in older patients and can be very difficult to treat. Many periprosthetic fractures will be treated operatively but there is a role for nonoperative management in certain circumstances. Most periprosthetic fractures associated with arthroplasty will occur in the femur following hip or knee replacement. The classification and management of these is detailed in Chapter 23 but if the Vancouver classification11 of proximal femoral periprosthetic fractures is employed, most Type B and C fractures will be treated operatively with nonoperative treatment being reserved for stable Type A fractures (Fig. 6-50). The basic principle governing the use of nonoperative management is that the fractures should be undisplaced or minimally displaced and the implant should not be loose. If these conditions apply, type A proximal femoral periprosthetic fractures can be treated by a period of restricted weight bearing. 
Figure 6-50
A Vancouver Type A fracture around the proximal stem of a stable bipolar prosthesis.
 
This type of periprosthetic fracture generally does not need surgical treatment.
This type of periprosthetic fracture generally does not need surgical treatment.
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Figure 6-50
A Vancouver Type A fracture around the proximal stem of a stable bipolar prosthesis.
This type of periprosthetic fracture generally does not need surgical treatment.
This type of periprosthetic fracture generally does not need surgical treatment.
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The same basic principle applies to periprosthetic fractures affecting the acetabulum or distal femur. Minor undisplaced perioperative acetabular fractures are sometimes caused by the insertion of hemiarthroplasty prosthesis in the treatment of proximal femoral fractures. These can be treated nonoperatively with a period of restricted weight bearing. More severe displaced acetabular fractures are usually treated operatively. In the distal femur Lewis and Rorabeck58 type I fractures can be treated nonoperatively as they are undisplaced and stable, but type II and III fractures are best treated operatively. Again a period of restricted weight bearing is used. The same principles are applied to periprosthetic patellar and proximal tibial fractures. 
Humeral periprosthetic fractures can be very difficult to treat. They occur in elderly patients and analysis of implant failure has shown that loosening is relatively rare.75 Thus the surgeon may be faced with a type B104 periprosthetic fracture in osteopenic bone and a stable implant. An example of this is shown in Figure 6-51 in which there had been an earlier humeral diaphyseal fracture as well. Nonoperative management may be the only realistic option under these circumstances. Periprosthetic fractures associated with elbow or ankle arthroplasties are treated using the basic principles of fracture displacement and implant stability that have already been outlined. 
Figure 6-51
A periprosthetic fracture that is virtually impossible to treat surgically.
 
A Vancouver Type B fracture in a humerus with an old nonoperatively managed diaphyseal fracture in an 89-year-old female. The shoulder was already very stiff.
A Vancouver Type B fracture in a humerus with an old nonoperatively managed diaphyseal fracture in an 89-year-old female. The shoulder was already very stiff.
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Figure 6-51
A periprosthetic fracture that is virtually impossible to treat surgically.
A Vancouver Type B fracture in a humerus with an old nonoperatively managed diaphyseal fracture in an 89-year-old female. The shoulder was already very stiff.
A Vancouver Type B fracture in a humerus with an old nonoperatively managed diaphyseal fracture in an 89-year-old female. The shoulder was already very stiff.
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In recent years there has been an increasing prevalence of femoral fractures associated with proximal femoral fracture fixation. These are most commonly associated with proximal femoral nails but may occur after the use of compression and dynamic hip screws. These fractures are usually displaced and there is little role for nonoperative management. 

Stress Fractures

There are two types of stress fracture: Fatigue fractures and insufficiency fractures. They are discussed in Chapter 21. Fatigue fractures usually occur in younger patients and, with the exception of some fractures of the proximal femur, femoral diaphysis, distal femur, and tibial diaphysis they are usually undisplaced and are managed nonoperatively (Fig. 6-52). The general principles of management are the same as described for other fractures and the same treatment regimes outlined in Tables 6-9 and 6-10 should be followed. Insufficiency fractures occur in abnormal bone and obviously the most common causes for these fractures are osteopenia and osteoporosis. Many of these fractures are undisplaced and nonoperative management will be used. The treatments outlined in Tables 6-9 and 6-10 should be followed. 
Figure 6-52
A stress fracture of the second metatarsal.
 
The treatment is nonoperative.
The treatment is nonoperative.
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Figure 6-52
A stress fracture of the second metatarsal.
The treatment is nonoperative.
The treatment is nonoperative.
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Metastatic Fractures

Metastatic fractures are discussed in Chapter 22. It is difficult to be prescriptive about the role of nonoperative treatment as it largely depends on the location of the fracture, the type of tumor, and the medical condition of the patient. Generally speaking, most metastatic fractures are treated operatively unless the patient has a very short life expectancy as surgical stabilization will diminish pain and improve the quality of the patient’s remaining life. 

The Future of Nonoperative Fracture Treatment

There are two principal competing factors that will determine the role of nonoperative management of fractures in the future. It is likely that fracture fixation techniques will become more sophisticated and fractures that we now treat nonoperatively may be shown in the future to have better results if treated operatively. It is certain that in many parts of the world the population that is going to present with fractures is the elderly population and it is highly likely that the patients who present with fractures in the future will be older and less fit than current patients. Future fracture research will need to determine the role of operative management in elderly patients who already have functional impairment and significant medical comorbidities. It seems likely that as we develop into a “super-elderly” population we will re-evaluate the role of nonoperative management in many fractures. 
Surgeons have analyzed the properties of osteoporotic bone in the belief that better fixation methods will improve the outcome of fractures in the elderly, but it is also necessary to consider the effect of aging on soft tissues and their recovery after injury and surgery. It may well be that the effect of increasing age on muscles, tendons, ligaments, and other soft tissues will negate any advantages gained by improved operative fixation but only time will tell. 
Overall it seems likely that the prevalence of operative treatment will rise, but probably not as quickly as has been the case in the last 30 to 40 years. Improved vehicle design together with enhanced industrial legislation, speed restrictions, and drinking and driving laws will continue to reduce the incidence of severe injuries but there is no doubt that orthopedic surgeons will be faced with an epidemic of less-severe fractures in the elderly. 

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