CONSERVATIVE MANAGEMENT OF FRACTURE

WHEN TO MANAGE CONSERVATIVE AND WHEN TO OPERATE

1. CONSERVATIVE
TREATMENT OF
FRACTURE ‘WHEN
TO DO IT’AND WHEN
NOT TO DO’
DR NAVEED JUMANI

2. Background
•Closed treatment of fractures” was very elaborately and scientifically described by Sir John
Charnley is his monograph in 1950.
•Earliest example of non-operative active treatment of fractures in humans was discovered
by G. Elliot Smith during his Egyptian expedition in 1903.
•Over the years it was propagated by Sir Robert Jones (1857–1933), who demonstrated
effectively the importance of life saving potential of the ‘Thomas splint’ invented by his
uncle Hugh Owen Thomas (1834–1891) in reducing the mortality due to open femoral
fractures sustained in World War-I from 80% to 20%.

3. Introduction
•Conservative management of fractures has shown good results in a
variety of fractures in the current generation particularly in upper
limb injuries and the use of Sarmiento functional bracing techniques
in tibial fractures.
•Decision becomes more pragmatic in managing lower limb
‘obligatory’ fractures such as hip injuries where weight bearing
mobilization is essential to avoid problems of recumbence and
immobility.

4. What is fracture
•Break in the structural continuity of bone.

5. Fracture management
•Four R in fracture management
1.Recognise the fracture…….always
2.Reduce the fracture…….if possible
3.Maintain reduction ……..always
4.Rehablitation ……..always

6. Recognise fracture
•History
–Mechanism of injury
–Associated injuries
–Neuro vascular injuries
–Site of injury
–Open or closed
–Position of limb
•Examination
–Look, feel, move.
•Investigation
–X-rays of affected extremity
–Helps classify the fracture
•At least 2 views with joint above and joint below
–CT SCAN

7. Why do we have
classifications?
•Organize knowledge
•Transfer information
•Guide treatment
•Estimate prognosis
•Enhance education and communication

8. History of Classification
Systems
•Ancient Egypt
•The Edwin Smith Papyrus classified injuries as:
–“An ailment which I will treat”
–“An ailment with which I will contend”
–“An ailment not to be treated”

9. •18th and 19th Century
•Descriptive classifications based on
appearance of limb
•“Dinner Fork Deformity”

10. •20th Century
•The advent of radiographs created numerous
classification systems
–Brought about the ability to identify location, amount, and
displacement of fracture lines
–Not without problems as radiographic views and quality can be
inconsistent
•The last 40 Years
–CT has allowed for further understanding and classification of intra-
articular fractures

11. •Believe it or not there’s more to consider than
just bones!
–X-rays or CT alone can underestimate the severity of the overall
injury and don’t consider patient status

12. Types of Classification Systems
•Fracture-Specific
–Garden –guides management/surgical plan
–Neer –assists describing fracture for communication
–Schatzker –can predict associated injuries and prognosis
–Lauge-Hansen –provides insight into mechanism
–Sanders -an example of CT-based classification
•Universal
–OTA/AO Classification
•Soft Tissue Injury Associated with Fracture
–Oesterne and Tscherne Classification
–Gustilo-Anderson Classification
–OTA Open Fracture Classification

13. Reduce the fracture
•All displaced fractures should be reduced to
minimize soft tissue complications, including those
that require ORIF
•Use splints initially
–Allow for swelling
–Adequately pad all bony prominences

14. Closed Reduction Principles
•Adequate analgesia and muscle relaxation are critical for
success
•Reduction maneuver may be specific for fracture location
and pattern
•Correct/restore length, rotation, and angulation
•Immobilize joint above and below

15. Closed Reduction Principles
•Reduction may require reversal of mechanism of injury, especially in
children with intact periosteum
•When the bone breaks because of bending, the soft tissues disrupt on
the convex side and remain intact on the concave side
Figure from Chapman’s Orthopaedic Surgery 3
rd
Ed. (Redrawn from Charnley J. The Closed
Treatment of Common Fractures, 3rd ed.
Baltimore: Williams & Wilkins, 1963.)

16. Closed Reduction Principles
•Longitudinal traction may not allow the fragments to be disimpacted and
brought out to length if there is an intact soft-tissue hinge (typically seen
in children who have strong perisoteum that is intact on one side)
Figure from Chapman’s Orthopaedic Surgery 3
rd
Ed. (Redrawn from Charnley J. The Closed
Treatment of Common Fractures, 3rd ed.
Baltimore: Williams & Wilkins, 1963.)

17. Closed Reduction Principles
•Reproduction of the mechanism of fracture to hook on the
ends of the fracture
•Angulation beyond 90°is usually required
Figure from Chapman’s Orthopaedic Surgery 3
rd
Ed.
(Redrawn from Charnley J. The Closed Treatment of
Common Fractures, 3rd ed. Baltimore: Williams &
Wilkins, 1963.)

18. Closed Reduction Principles
•Three point contact (mold) is
necessary to maintain closed
reduction
Figure from: Rockwood and Green:
Fractures in Adults, 4
th
ed, Lippincott,
1996.
•Removal of any of the three forces
results in loss of reduction

19. Anesthesia for Closed Reduction
IV Sedation:
•Technique:This typically involves combining an opioid (morphine or
fentanyl) for analgesia and a benzodiazepine (midazolam) for sedation,
relaxation, and amnesia.
•Morphine -0.1 mg/kg
•Meperidine (Demerol) -1-2 mg/kg up to 150 mg
•Beware of pulmonary complications with deep conscious sedation -
consider anesthesia service assistance if there is concern
•Pulse oximeter and careful monitoring are recommended
•Reversal medications (naloxone, flumazenil)

20. Anesthesia for Closed Reduction
•Hematoma Block-aspirate hematoma and place Lidocaine
at fracture site
•Lidocaine: 5 mg/kg (7 mg/kg if combined with epinephrine)
–30-kg child, 1% lidocaine without epinephrine
•10 mg/mL of lidocaine
•5 mg/kg ×30 kg = 150 mg allowed
•150 mg/10 mg/mL = 15 mL of 1% lidocaine
–Fast and easy,Short acting.
–Most widely used local anesthetic
–Theoretically converts closed fracture to open fracture but no
documented increase in infection
–Wait 5 to 7 minutes, then perform the reduction maneuver.

21. Anesthesia for Closed Reduction
•Regional Blocks:
–Digital Block: Use about 2 mL per nerve (8 mL total).
–Wrist Block
–Elbow Block
–Axillary Block
–Beirs Block
–Popliteal Block
–Ankle Block

22. Regional Blocks

23. Regional Blocks

24. Maintain reduction
•Holding the fracture reduced and keeping it reduced in a supported
environment (such as a cast or splint) till the fracture heals.
•Reduction could be maintained by:
–Bandages
–‘splints
–Cast
–Traction
–External fixation
–Internal fixation

25. Common Splinting Techniques
•Bulky” Jones
•Sugar-tong
•Coaptation
•Ulnar gutter
•Volar / Dorsal hand
•Thumb spica
•Posterior slab (ankle) +/-U splint
•Posterior slab (thigh)

26. Sugar Tong Splint
•Splint extends around the
distal humerus to provide
rotational control
•Padding should be at least
3 -4 layers thick with
several extra layers at the
elbow

27. •Medially splint ends in the
axilla and must be well
padded to avoid skin
breakdown
•Lateral aspect of splint
extends over the deltoid
Figure from Rockwood and Green, 4
th
ed.
Humeral Shaft Fracture Coaptation Splint

28. Fracture Bracing
•Allows for early functional ROM and weight bearing
•Relies on intact soft tissues and muscle envelope to
maintain alignment and length
•Most commonly used for humeral shaft and tibial shaft
fractures

29. •Convert to humeral fracture brace 7-10 days
after fracture
(i.e. when fracture site is not tender to
compression).
•Allows early active elbow ROM
•Fracture reduction maintained by hydrostatic
column principle
•Co-contraction of muscles
-Snug brace during the day
-Do not rest elbow on table
Patient must tolerate a snug
fit for brace to be functional
Figure from Rockwood and Green, 4th ed.

30. Casting
•Goal of semi-rigid immobilization while avoiding pressure
/ skin complications
•Often a poor choice in the treatment of acute fractures
due to swelling and soft tissue complications
•Good cast technique necessary to achieve predictable
results

31. Casting Techniques
•Stockinette -may require two different diameters to
avoid overtight or loose material
•Caution not to lift leg by stockinette –stretching the
stockinette too tight around the heel may case high skin
pressure

32. Casting Techniques
•To avoid wrinkles in the
stockineete, cut along the
concave surface and
overlap to produce a
smooth contour
Figure from Chapman’s Orthopaedic
Surgery 3
rd
Ed.

33. Casting Techniques
•Cast padding
–Roll distal to proximal
–50 % overlap
–2 layers minimum
–Extra padding at fibular
head, malleoli, patella, and
olecranon
Figure from Chapman’s Orthopaedic
Surgery 3
rd
Ed.

34. Plaster vs. Fiberglass
•Plaster
–Use cold water to maximize molding time
•Fiberglass
–More difficult to mold but more durable and resistant to
breakdown
–Generally 2 -3 times stronger for any given thickness

35. Width
•Casting materials are available in various widths
–6 inch for thigh
–3 -4 inch for lower leg
–3 -4 inch for upper arm
–2 -4 inch for forearm

36. Figure from Chapman’s Orthopaedic
Surgery 3
rd
Ed.
•Avoid molding with anything
but the heels of the palm in
order to avoid pressure points
•Mold applied to produce three
point fixation
Cast Molding

37. Complications of Casts &
Splints
•Loss of reduction
•Pressure necrosis –may occur as early as 2 hours
•Tight cast compartment syndrome
–Univalving = 30% pressure drop
–Bivalving = 60% pressure drop
–Also need to cut cast padding

38. Complications of Casts &
Splints
•Thermal Injury -avoid plaster > 10 ply, water >24°C, unusual with
fiberglass
•Cuts and burns during removal
Keloid formation as a result of an injury
during cast removal. From Halanski M,
Noonan KJ. J Am Acad Orthop Surg. 2008.

39. Complications of Casts &
Splints
•DVT/PE-increased in lower extremity fracture
–Ask about prior history and family history
–Birth Control Pills are a risk factor
–Indications for prophylaxis controversial in patients without risk
factors
•Joint stiffness
–Leave joints free when possible (ie. thumb MCP for below elbow
cast)
–Place joint in position of function

40. Traction
•Allows constant controlled force for initial stabilization of long bone
fractures and aids in reduction during operative procedure
•Option for skeletal vs. skin traction is case dependent

41. Skin Traction
•Limited force can be applied -generally not to exceed 5 lbs
•More commonly used in pediatric patients
•Can cause soft tissue problems especially in elderly or
rheumatoid patients
•Not as powerful when used during operative procedure for both
length or rotational control

42. Skin Traction -“Bucks”
•An option to provide temporary comfort in hip fractures
•Maximal weight -10 pounds
•Watch closely for skin problems, especially in elderly or rheumatoid
patients

43. Skeletal Traction
•More powerful than skin traction
•May pull up to 20% of body weight for the lower extremity
•Requires local anesthesia for pin insertion if patient is awake
•Preferred method of temporizing long bone, pelvic, and acetabular
fractures until operative treatment can be performed

44. Traction Pin Types
•Choice of thin wire vs. Steinman pin
•Thin wire is more difficult to insert with hand drill and requires a
tension traction bow
Tension Bow
Standard Bow

45. Traction Pin Types
•Steinmann pin may be either smooth or
threaded
–Smooth is stronger but can slide if angled
–Threaded pin is weaker, bends easier with higher
weight, but will not slide and will advance easily
during insertion
•In general a 5 or 6 mm diameter pin is chosen
for adults

46. Traction Pin Placement
•Sterile field with limb exposed
•Local anesthesia +sedation
•Insert pin from known area of neurovascular structure
–Distal femur: Medial Lateral
–Proximal Tibial: Lateral Medial
–Calcaneus: Medial Lateral
•Place sterile dressing around pin site
•Place protective caps over sharp pin ends

47. Distal Femoral Traction
•Method of choice for acetabular and proximal femur fractures
•If there is a knee ligament injury usually use distal femur instead of proximal
tibial traction

48. Distal Femoral Traction
•Place pin from medial to lateralat
the adductor tubercle -slightly
proximal to epicondyle
Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.

49. Balanced Skeletal Traction
•Allows for suspension of leg with longitudinal traction
•Requires trapeze bar, traction cord, and pulleys
•Provides greater comfort and ease of movement
•Allows multiple adjustments for optimal fracture alignment

50. •One of many options for setting up balanced suspension
•In general the thigh support only requires 5-10 lbs of weight
•Note the use of double pulleys at the foot to decrease the total weight
suspended off the bottom of the bed
Figure from: Rockwood and Green: Fractures in Adults, 4
th
ed, Lippincott, 1996.

51. Proximal Tibial Traction
•Place pin 2 cm posterior and 1
cm distal to tubercle
•Place pin from lateral to medial
•Cut skin and try to stay out of
anterior compartment -push
muscle posteriorly with pin or
hemostat
Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.

52. Calcaneal Traction
•Most commonly used with a spanning
ex fix for “travelling traction” or may be
used with a Bohler-Braun frame
•Place pin medial to lateral2 -2.5
cm posterior and inferior to medial
malleolus
Medial Structures
Lateral Structures
Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.

53. Olecranon Traction
•Rarely used today
•Small to medium sized pin placed from
medial to lateral in proximal olecranon -
enter bone 1.5 cm from tip of olecranon
and walk pin up and down to confirm
midsubstance location.
•Support forearm and wrist with skin
traction -elbow at 90 degrees
Figure from Chapman’s Orthopaedic
Surgery 3
rd
Ed.

54. Gardner Wells Tongs
•Used for C-spine reduction / traction
•Pins are placed one finger breadth above pinna, slightly
posterior to external auditory meatus
•Apply traction beginning at 5 lbs. and increasing in 5 lb.
increments with serial radiographs and clinical exam

55. Halo
•Indicated for certain cervical fractures as definitive
treatment or supplementary protection to internal fixation
•Disadvantages
–Pin problems
–Respiratory compromise

56. Left: “Safe zone” for halo pins. Place anterior pins about 1 cm above orbital rim,
over lateral two thirds of the orbit, and below skull equator (widest circumference).
Right: “Safe zone” avoids temporalis muscle and fossa laterally, and supraorbital and
supatrochlear nerves and frontal sinus medially.
Posterior pin placement is much less critical because the lack of neuromuscular
structures and uniform thickness of the posterior skull.
Figure from: Botte MJ, et al. J Amer Acad Orthop Surg. 4(1): 44 –53, 1996.

57. Halo Application
•Position patient maintaining spine
precautions
•Fit Halo ring
•Prep pin sites
–Anterior -outer half above eyebrow avoiding
supraorbital artery, nerve, and sinus
–Posterior -superior and posterior to ear
•Tighten pins to 6 -8ft-lbs.
•Retighten if loose
–Pins only once at 24 hours
–Frame prn
Figure from: Rockwood and Green:
Fractures in Adults, 4th ed, Lippincott, 1996.

58. ‘WHEN TO DO IT’AND WHEN
NOT TO DO’
Indications and Contraindications for conservative management of
Paediatric fractures and dislocations

59. Suggested Indications and Contraindications for
Conservative Management of fractures and dislocations in
adults

60. Conclusion
•Conservative, non-operative therapeutic approach may also provide an
alternative in non-obligatory fractures in the current COVID-19 pandemic
(and perhaps later on as well).
•We must realize that all the fractures do not always need operations and the
conservative management still has a certain place in our armamentarium of
fracture management, in an evolving world!