Non-Operative Treatment of Fractures — Types, Indications, Techniques

Introduction

Non-operative (conservative) fracture treatment remains the appropriate management for the great majority of fractures encountered in clinical practice. The principles of reduction, immobilization, and functional restoration that underlie non-operative care date back to antiquity, and modern non-operative techniques have benefited from improvements in materials, understanding of biology, and rehabilitation principles. This chapter synthesizes content from AO Principles of Fracture Management, Apley & Solomon’s, Miller’s Review, and Rockwood and Green’s, addressing the indications for non-operative treatment, the techniques of closed reduction and immobilization, the materials and methods of cast and splint application, the principles of traction, and the management of specific common fracture types.

Indications for Non-Operative Treatment

The decision between non-operative and operative treatment is the cardinal decision in fracture management. The principal factors include: Fracture characteristics: Non-displaced or minimally displaced fractures; stable fracture patterns; fractures with acceptable position; fractures expected to heal without complication under closed treatment. Patient factors: Medical conditions precluding anesthesia or surgery; advanced age with limited functional demands; patient preference; specific contraindications to surgery. Anatomical and functional considerations: Fractures in expendable bones (rib, clavicle in many cases, scapula in many cases); fractures with high success rates of closed treatment (most clavicle, most rib, many tibial shaft, many humeral shaft, distal radius without significant displacement, many ankle); paediatric fractures with substantial remodeling potential. Specific contraindications to operative treatment: Active infection; severe contamination; poor soft-tissue envelope at the proposed surgical site; patient unable to comply with postoperative protocol.

Principles of Closed Reduction

Closed reduction — the restoration of fracture fragments to acceptable position without surgical exposure — is the foundation of non-operative fracture treatment. Goals of Reduction The goal of reduction varies with the specific fracture. The four principal parameters are:

Length: Restoration of normal bone length. Substantial shortening produces functional disability and is generally unacceptable. Alignment (angulation): Restoration of normal angular alignment in both the sagittal (apex-anterior/posterior) and coronal (apex-medial/lateral) planes. The acceptable angulation varies with the bone, the age of the patient, and the proximity of the fracture to a joint. Children tolerate substantial angulation with remodeling; angulation in adults is generally less well tolerated. Rotation: Rotational malalignment is poorly tolerated functionally and does not remodel over time. Rotational reduction must be achieved at the time of treatment. Translation: Side-to-side displacement of fragments. Some translation is acceptable in many diaphyseal fractures provided length and alignment are restored. The phrase “acceptable reduction” implies that not every fracture requires anatomical reduction. Articular fractures generally require anatomical reduction (gaps and steps of more than 1-2 mm typically demanding surgical management); diaphyseal fractures tolerate more imperfect reduction with adequate functional outcomes. Techniques of Reduction Closed reduction techniques include: Direct manipulation: The classical approach. The bone is palpated, the displacement is assessed, and direct manual pressure is applied to restore alignment. Adequate analgesia (often regional or general anesthesia, particularly for major fractures or for older children) is essential. The technique of “exaggerating the deformity” — first exaggerating the deformity to disengage the fragments, then reversing the deformity to reduce them — is the classical maneuver for many fractures (typified by the reduction of distal radius fractures). Traction-countertraction: Continuous longitudinal traction along the long axis of the bone, combined with countertraction in the opposite direction, gradually realigns the fragments. The technique is essential for many lower limb fractures and is often combined with direct manipulation. The fracture table, with its specific traction and positioning features, is used for many lower limb fractures. Continuous traction: Various forms of traction (skin traction with adhesive strapping, skeletal traction with pins through bone) are used for both initial reduction and for definitive treatment of certain fractures (historically the principal method for femoral shaft fractures in adults; still used in selected paediatric femoral fractures and as a temporizing measure in some adult fractures). The selection of reduction technique depends on the specific fracture, the patient’s medical condition, and the available facilities.

Materials of Immobilization

Plaster of Paris Plaster of Paris (calcium sulfate hemihydrate) is the classical material for cast immobilization. The plaster sets through an exothermic chemical reaction when mixed with water. Advantages include low cost, ease of moulding to the limb contour, and reliable hardening. Disadvantages include weight, fragility when wet, slow setting, and the small risk of thermal injury during setting (particularly with hot water or multiple layers). Fiberglass Fiberglass casting materials, introduced in the 1980s, have largely replaced plaster of Paris in modern practice for many applications. Advantages include lighter weight, greater strength, water resistance, and faster setting. Disadvantages include higher cost, less plastic moulding ability, and the difficulty of removal in some emergencies (though specialized cast saws address this). Other Materials Aluminium and other malleable splints: Used for finger and toe splints. Pre-formed orthoses: Functional braces for various fractures (the Sarmiento functional brace for humeral shaft and tibial fractures is the classical example), with the brace allowing controlled motion while supporting the fracture. Air casts and walking boots: Used for stable ankle and foot fractures, with the advantage of being removable for bathing and skin care. Bandages and strapping: For specific applications (figure-of-eight strapping for clavicle fractures, buddy strapping for stable finger fractures).

Cast Application — Principles and Technique

The principles of cast application include: Three-point fixation: The classical principle that any cast must apply pressure at three points along the bone — at the proximal fragment, at the distal fragment, and at the apex of the deformity — to maintain reduction. The points of pressure are critical to preventing displacement during the healing period. Immobilization of the joints above and below: The classical teaching that immobilization should extend across the joints proximal and distal to the fracture to prevent motion at the fracture site. Modern functional bracing challenges this for some fractures, recognizing that the joint motion can be permitted while the fracture itself is protected. Appropriate padding: Adequate padding over bony prominences and along the limb to prevent pressure sores, with sufficient additional padding to permit anticipated swelling.

The principal vulnerable sites are the malleoli, the calcaneus, the patella, the olecranon, the dorsum of the wrist, and the bony prominences of the foot. Molding: Careful molding of the cast over the bony anatomy and at the points of three- point fixation to maintain reduction. The “interosseous space” must be preserved between the radius and ulna (and between the tibia and fibula) by appropriate molding. Adequate length: The cast must be long enough to permit effective three-point fixation but not so long as to immobilize unnecessary joints. Univalving or bivalving for swelling: In the acute fracture, the cast is typically univalved (cut longitudinally on one side) or bivalved (cut on both sides) to permit expansion as the limb swells. The cast is reapplied or replaced after swelling has resolved. Specific Cast Types Below-knee cast: Ankle and foot fractures. Above-knee cast: Tibial and fibular fractures, with the knee at variable flexion depending on the fracture. Hip spica: Femoral fractures in young children; pelvic and acetabular fractures historically. Long-arm cast: Forearm and elbow fractures. Short-arm cast: Distal forearm and wrist fractures. Thumb spica: Scaphoid fractures and thumb metacarpal fractures. Figure-of-eight harness: Clavicle fractures (now less commonly used). Velpeau dressing: Proximal humerus and shoulder injuries in elderly patients.

Complications of Cast Treatment

The complications of cast treatment are well-documented and largely preventable with appropriate technique. Compartment syndrome: Increased pressure within a fascial compartment beneath the cast. Recognized by severe pain disproportionate to the apparent injury, pain on passive stretch of the muscles, sensory disturbance, and tense compartments on palpation. Treatment is urgent univalving of the cast (or, if this is inadequate, removal of the cast) and emergency fasciotomy. Pressure sores: From inadequate padding, particularly over bony prominences, or from foreign objects placed within the cast (the classical insertion of pencils to scratch underneath the cast). Patient education and proper technique are the principal preventive measures.

Cast-induced peripheral nerve injury: From direct compression of nerves at superficial locations (peroneal nerve at the fibular neck; ulnar nerve at the elbow; radial nerve in the spiral groove). Adequate padding and careful inspection at follow-up visits are essential. Joint stiffness: Particularly of joints immobilized by the cast, with shoulder stiffness (“frozen shoulder”) and finger stiffness being recognized concerns after upper limb casts. Disuse atrophy: Of muscles within the cast, requiring rehabilitation after cast removal. Cast disease (cast syndrome): A historical term for the constellation of nausea, vomiting, and abdominal distention sometimes seen with hip spica casts in adolescents, attributed to superior mesenteric artery compression of the duodenum. Skin maceration: From moisture trapped within the cast, particularly with plaster casts that become wet. Cast loosening: As swelling reduces, the cast becomes loose and ineffective; cast replacement or reapplication may be required.

Traction

Traction is the application of pulling force along the long axis of a limb to restore length and alignment. Skin Traction Skin traction applies traction through adhesive strapping or specialized boots attached to the skin. The amount of traction is limited (typically less than 5 kg in adults) and is therefore suitable principally for temporary stabilization, for paediatric applications, and for selected definitive treatment in certain situations. Russell’s traction and the various paediatric traction systems are examples. Skeletal Traction Skeletal traction applies traction through pins inserted into bone, allowing much greater forces (up to 10-15% of body weight) and more reliable maintenance of reduction. The principal pin sites include the distal femur (for hip and proximal femoral fractures, and for femoral fractures requiring traction), the proximal tibia (for distal femoral and tibial plateau fractures), and the calcaneus (for tibial fractures). Risks include pin-tract infection, pin loosening, and neurovascular injury during pin insertion. Indications for Traction In modern practice, traction is principally used as a temporizing measure before definitive surgical fixation, particularly for: femoral neck and intertrochanteric fractures awaiting surgery; femoral shaft fractures awaiting surgery; tibial plateau and pilon fractures awaiting surgery once soft-tissue swelling has resolved; spinal injuries; and certain paediatric fractures.

Definitive treatment with traction alone is now uncommon but is still occasionally used for paediatric femoral shaft fractures, for certain pelvic injuries in selected patients, and in resource-limited settings.

Functional Bracing

Functional bracing, popularized by Augusto Sarmiento and others from the 1960s, uses a prefabricated brace that permits motion at the joints adjacent to the fracture while supporting the fracture itself through hydraulic principles of soft-tissue compression. The classical applications include humeral shaft fractures (the Sarmiento humeral brace) and tibial fractures (the Sarmiento PTB brace). The advantages of functional bracing include: maintenance of joint motion and muscle strength during fracture healing; better patient acceptance than rigid casts; faster return to function; and reduced rates of joint stiffness. The disadvantages include the need for cooperative patients, the requirement for skilled application and follow-up, and the limited application to specific fracture types.

Closed Reduction Under Anesthesia

For displaced fractures that cannot be adequately reduced under simple analgesia, closed reduction under anesthesia is performed. The procedure is typically performed under general or regional anesthesia, with image intensifier guidance, in the operating theater or in a procedure room with appropriate facilities. The technique involves: application of anesthesia; positioning of the patient appropriate to the fracture; reduction maneuvers using direct manipulation, traction, and three-point fixation; verification of reduction by fluoroscopy; application of a definitive cast or splint; and final radiographs to document the reduction. Specific named reduction techniques include the Kocher and Hippocratic methods for shoulder dislocation, the Stimson maneuver for shoulder and hip dislocations, the Allis maneuver for hip dislocation, and many others. The choice of technique depends on the specific injury and the surgeon’s experience.

Specific Considerations by Fracture Type

The detailed management of specific fractures is addressed in the relevant anatomical chapters; the general principles for each major fracture type include: Clavicle fractures: Most can be treated non-operatively with sling support, with surgical management for specific indications (severe displacement, open fractures, neurovascular compromise, polytrauma). Proximal humerus fractures: Most non-displaced and minimally displaced fractures heal well with sling immobilization for 4-6 weeks followed by progressive rehabilitation; displaced 2-, 3-, and 4-part fractures require more individualized assessment with surgical management in selected cases.

Humeral shaft fractures: Most heal well with Sarmiento functional brace; surgical management for specific indications (radial nerve palsy with confirmed transection, segmental fractures, open fractures, polytrauma). Distal radius fractures: Most extra-articular fractures heal well with closed reduction and casting; intra-articular fractures and unstable fractures may require surgical fixation. Stable ankle fractures: Many lateral malleolus fractures and other stable patterns heal well with cast or walking boot immobilization; unstable patterns require surgical fixation. Stable tibial shaft fractures: Some can be treated with Sarmiento brace or long-leg cast; the trend has shifted toward intramedullary nailing for most displaced tibial shaft fractures. Stable foot fractures: Most metatarsal and toe fractures heal well with appropriate footwear modification, with surgery reserved for displaced articular fractures, segmental injuries, and specific patterns. Vertebral compression fractures: Most stable osteoporotic vertebral compression fractures heal with conservative management (analgesics, bracing, gradual mobilization); surgical management (vertebroplasty, kyphoplasty, instrumented fusion) for selected patients. Paediatric fractures: A large proportion of paediatric fractures heal with closed reduction and casting because of the substantial remodeling capacity of growing bone.

Rehabilitation After Closed Treatment

Rehabilitation after non-operative fracture treatment is critical to functional recovery. The principles include: Maintaining motion at uninvolved joints during the immobilization period. Even when the affected joint must be immobilized, the joints proximal and distal to the cast should be moved through their range of motion daily. Edge of cast exercises: Active movement at the joints at the edges of the cast to maintain muscle bulk and circulation. Weight-bearing as appropriate: Following the fracture-specific protocol, with progressive weight-bearing as healing progresses. Range-of-motion exercises after cast removal: Often requiring formal physiotherapy. Progressive strengthening: Gradual return to functional activities and sports. Return to activity criteria: Based on clinical and radiographic healing, return of motion, return of strength, and patient symptoms.

Summary and Take-Home Points

Non-operative fracture treatment remains the appropriate management for the great majority of fractures, with techniques including closed reduction, cast and splint immobilization, traction, and functional bracing. The cardinal principles of non-operative care — restoration of length, alignment, rotation, and translation; appropriate immobilization with attention to three-point fixation; appropriate cast technique including padding, molding, and bivalving for acute swelling; and progressive rehabilitation — produce successful outcomes in the great majority of cases. The complications of cast treatment (compartment syndrome, pressure sores, peripheral nerve injury, joint stiffness, disuse atrophy) are largely preventable with appropriate technique and follow-up. Traction is principally used as a temporizing measure before definitive surgery in modern practice, with definitive treatment by traction alone becoming uncommon. Functional bracing permits joint motion during healing and has specific applications in humeral and tibial shaft fractures. The choice between non-operative and operative management is informed by fracture-specific, patient-specific, and contextual factors, with appropriate selection of management producing the best outcomes.