Chapter 5

Ovid: Rockwood & Green's Fractures in Adults
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Edi tors : Tit le:
Buchol z, Robe rt W.; Heckm an, J ames D.; Court-Brown , Charl es M.
Rock wood & Gre en's Fract ures i n Adults, 6th Ed itio n
C opyright 2006 Lippincott Willia ms & Wilki ns

> Ta bl e of Co nte nts > V olume 1 > Section On e - Gene ral Pri nc ip les > Ch apter 5 - Nonoper a tive Frac ture Trea tment
Chapter 5 Nonoperative Fracture Treatment

John F. Con nolly P.1 46
EFFECT OF TREATMENT ON SKELETAL REPAIR PROCESSES

W e vert ebrates h ave su rvived and flouris hed briefly by evolvin g effi cie nt pro ce sses of skele ta l repa ir a nd remodelin g. The y provi de u s no t only wit h bi omec ha nically ingen iou s sup po rt s tru ctu res for u pright l ocomo tion but also serve as dynamic h emopoietic a nd os teogenic production an d storage cen ter s. Such advan tages e volved eo ns bef ore fra ctu re surgeo ns ca me o n th e scene . O ssif icatio n is not petrifica ti on. The ske letal system is very active me ta bolical ly with a turno ver ra te o f 3% per year of cortic al an d 2 5% per yea r o f ca nc ello us bo ne (1). T his turno ver con trols repa ir an d ma intena nce of the matrix of skelet al s uppo rt an d also h elps regu late th e critical levels of calciu m in tissue fluids. In additio n, th e skelet a l marro w system pr o vides a h emopo ietic in duct ive mi cro enviro nment for the active produ ctio n of 3 00 to 400 b illion red cells a nd 100 t o 20 0 billio n w hite cel ls daily (2, 3). This incredible productivit y is increa se d signific antly in respon se to blood loss or infection. It also depends on the variable half-life of RBCs and WBCs. Marrow stem cells are the seeds n ot only for hemopoiesis b ut al so for skeletoge nesis. Hemopoieti c and stromal stem cells have been fo und esca ping contin uou sly in to th e blo odstr eam to replac e se nescent ce lls thro ugho ut th e bo dy (4). Th ey are t ho ught to c ontribut e s ignificantly to t he ma intena nce and integr ity of con nective ti ssue s th rough ou t the body includi ng bone an d muscle (2, 5,6). Th e ph ysi cian who treats patients with f ractu res should keep in mi nd th e effe ct of such treatment, e ither operative or no nope rative, o n t he p hysiologic mech anism s of skeletal main te nan ce an d repai r d erived from cre ative ve rteb ra te evolution (7 ) ove r at least 2 50 million years. For instance, repair of fractures h as e volved to accommo date for motion of the fra ctu re fragments. For many fractu re s, this mo tion betwe en fragments appears to stimulate th e e arly repair proce sses (8 ). Rib and clavicle fractures a re classic examples of the prompt heal ing th at u su ally occurs de spi te , or possibly because o f, interfragmentar y motio n. Fixatio n techniqu es, eithe r ope ra tive or n onoper ative, whic h elimin ate th is stim ulus of mo tion ( 9, 10), ca n sacrif ice th e gif t of evol ution -tes ted callus for the possibility of b etter cosmesis or function. For some fractures this sacrifice ma y be unrew arded or eve n co unterproductive. C on se quently, surgeon s must keep in mind tha t the treatment we select for the fracture is never a neutra l factor in th e outcome ( 11 , 12 ). Th e mec h anisms by whic h function al motio n stimul ates callu s f ormatio n and remodeli ng a re kn own to b e several , inclu ding vascular, bioele ctric, and b iochemica l. Some degree of mo tion a t the fracture site stimulates vascular ingrow th from soft tissu e a s well as from the medulla ry can al (1 3,14,15). Th is vascula r in growth carries an in vasion o f cells a s well as n utrients to f uel the hyperm etabo lic re sponse of fracture h ealin g. Additionally, intermittent load ing of the fracture site, ei th er with w eightbea rin g or by mus cle a ctivi ty shif ts the piezoe lectric balan ce of the co llage n-crys talli ne matri x. Th is appe ars to be th e switch that turns on the bioele ctric signals for osteoblasts to form n ew bone. Sh ear and c ompressive mo tion betwee n th e fracture fragments also break dow n bone matrix th ereby re leasing significant amou nts of stimulatory factors from th eir skeletal storehouse an d promoting b one f ormatio n (1 6).
A BRIEF HISTORY OF THE EVOLUTION OF FRACTURE TREATMENT

In contra st to the evoluti on of bi ologic processes of vertebrate repair occurring over millions of years, or thopaedic su rgi ca l repair of fractures has evolve d qui te briefly and rapidly. The primary su rgical tr ea tme nt o f many ope n fractur es i n th e Civil War era, for exam ple, was amp utat io n. O perat ive treatme nt of fractures, and indee d surgery on all previously i nviolate body structures, was ma de p ossible b y Lister's 18 65 devel opmen t of a ntiseptic t echn iques to trea t ope n tibia l and patella frac tur es (Table 5-1 ). Prio r to Lister's develo pm ent of safe antisept ic surgical techniq ues the main e mp hasis f or tho usands of yea rs was on no no per ative methods for frac tur e trea tmen t usin g a variety of splints, traction, or casts. A major objective was to find a P.1 47
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P.1 48 P.1 49 ma ter ial th at w ould allo w imm obiliza tion of th e fracture without requi rin g da ily cha nges of the i mmobiliz in g splint. It was not until military su rgeon s Mat hij esen and Piro gov in 185 2 utilized plast ero f-pa ri s techniqu es to im mo biliz e fr actures t h at thi s obj ecti ve wa s achi eved.
TABLE 5-1 Chronology of Nonoperative Fracture Treatment

Date Originator C ontribu ti on
30 00 BC
Imho te p
Possible Egyptian au th or of the Edwin Sm ith Pa pyrus describing reduction of fractures, and immobili zation with wood splints a nd ba ndage s.
40 0 BC
Hippo cra tes
Greek medical i con who described mechan ica l a ids to reduce f ra ctu res an d dislo cation s as well as in nova tive ba ndagin g techn iques.
16 0 AD
Galen
Ro man physician a nd anato mist who de scribed a wide variety of ba ndage s including a spica (wrapped with tu rn s crossing like ear of grain ).
10 00 AD
Albuca sis
Arab physician who a dvocated reducin g femoral fra ctu re with the knee flexed. Th is remain ed the po si ti on of ch oice for many hundreds of years. He a lso described plaster spl ints usin g flowe r, egg w hite, a nd other ingredients to support the fra ctu red limb. These dre ssin gs were chan ged in frequ ently.
13 63
de Cha ulia c
Fre nch cleri c and surgeon who prescribed isometric traction to the fractured leg by we ight a tta ch ed to a cord and pas sing thr ou gh a pu lley.
15 40
Pare
F re nch m ilit ary sur ge on and un su rpassed in no vator who described th e diffe re ntial diagn osis a nd trea tme nt of hip fra ctu res an d dislo cation s along wit h m any othe r clas sic wo rks.
17 65
Pott
Lo ndon s urgeo n who described ty pes o f ankle fra ctu re s and the mechan ics o f re duc ing fractur es to co untera ct m uscle force.
18 19
Dupuytren
Pa risian surgical giant who amo ng othe r wo rk s perform ed studies of expe rime ntal fractures in ca davers to ill ustra te mecha nisms o f inju ry an d techn iques of redu ctio n.
18 21
Barton
U.S. su rgeon wh o described the treatment of green sti ck fra ctu res in children an d the frac tu re-disl ocatio n of r adio carpal jo int th at be ars his name.
18 47
Smith
Dublin surgeo n and pathologist who clarif ied th e diffe re ntial diagn osis and tre atm ent o f wrist frac tur es in cl uding the
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Co lles and Sm ith frac tur e.
18 52
Mat hi jesen
Dutch a rmy surgeon who reporte d the use of pla ster-of-paris ban dages to immobilize fractures.
18 52
Pi rogov
Ru ssia n mi litary surgeo n who refined plas ter b andage techn iques a nd emphasized splinting fractu re s before movin g the inj ured.
18 60
H am il to n
New York su rge on an d au thor who co llec ted statistical ta bles detailing e nd re su lts of a large number of patien ts with a wide variety of fractures. This represented th e first outcome study to e sta blish stan dard o f c are. An impo rt ant i nflu ence on the result of ma lpractice s uits, w hich were preva lent in this co un try even in the 19 th cen tu ry.
18 61
Buck
U.S. military su rge on who po pula rized skin traction f or femoral fra ctu res with the knee extende d.
18 63
Ho dgen
U.S. physician who mo dif ied the leg splint for applyi ng skin traction to f emur fractures.
18 65
Lister
Glasgow, Scotland, surgeon who f irst applie d an tise pti c principle s to the treatme nt of open tibia l fractures, wh ich all owed no t o nly th e successful treatmen t o f these i njurie s wit ho ut amp utat io n but a lso gave bir th eve ntuall y to the en tire field of ope ra tive su rge ry.
18 75
Tho mas
Liverpo ol, Engla nd, bra ce maker w ho developed th e Th omas splint for imm o bilizing tuberc ulo sis knee s and fra ctures . This splint was credit ed fo r savi ng ma ny lives o f Wo rld W ar I soldiers with femu r fractu res that ha d been le ft unstabilized. Thomas promoted the treatme nt of fra ctu re s by restabsolute, unin te rru pte d, and prolonged. Th is wa s ado pted for treatment of infections as w ell as fractures and inf lue nced s eve ra l gen eratio ns o f Engli sh an d U .S . orthopae dic surgeons.
18 76
Ch ampio nnie re
F re nch su rgeon wh o oppo se d the Tho mas adv ocacy of tr eating fra ctu res by re st and ad vo cated mo bilizatio n and mas sage of mu scle s particula rl y aro und jo ints. He emphasized th at restora tion of function was not re lated to restoration of shape or length of the limb. These two con tra sting approaches to fra cture treatment by e ith er rest o r active motio n rema ined a so urce of deba te for th e n ext centu ry between C ontin ental an d Anglo -Ame ri ca n o rth opae dic sur geo ns.
19 07
St einma nn
Ber lin s urgeo n who descr ibed type o f tra ctio n using a pin in the dis tal femur, whic h ha s become the s ta ndard for femora l fra ctu res.
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19 19
Pe arson
Utili zed a n ice- ton g cal iper in se rted in t he distal femur for traction an d a lso devised a n a tta chment to th e Th omas splint to allo w kn ee flexio n.
19 20
Delbet
F re nch ortho paedic su rgeon who described tec hniq ues of closed reduction of tibial fra ctu re s and applica tion of plaster splints to permit weigh tbe aring tre atment of these fractures.
19 21
Ru ssel l
Aus tr alia n su rge on who de vis ed a techni que of skin tr action for th e f em ora l a nd h ip frac tures , wh ic h a llowe d flexio n o f the hip and knee usin g a do uble pulley syste m fo r mecha nical advan tage.
19 27
Kirschne r
Develo ped skele ta l tractio n using a thi n wi re drilled throu gh the fe mur a nd a ten sio n bow to mainta in rigi dit y o f th e w ire .
19 29
h ler
Aus tr ian surgeo n who publi sh ed a classic text on nonoperative tre atment of fra ctu res an d particul arly emphasized organized trauma cen ters to ca re for industrial an d other i njurie s. He furt her popu larized the use of skeletal traction for tib ia fractures and ski ntight w alking plaster after the fra ctu re ha d pa rtia lly h ealed.
19 50
Ch arnley
Liver po ol, Engla nd, o rt ho paed ic su rge on who se text on t he closed treatment of co mmon fra ctu re s refl ected the teachin g o f H. O. Thoma s and Robert Jones. This leadin g o rth opa edic inn ova to r e mp hasized both the biomech anics a nd th e techn iques o f fra ctu re redu ctio n as we ll as the advan ta ges o f nonoperative tre atment of f ra ctu res.
19 59
Dehne
U.S. military orthopaedic su rge on who po pula rized B hler's weigh tbearing technique for treatment of tibia fra ctu res in the Un ited States.
19 67
Sarmiento
Miami ortho paed i c surgeo n w ho applie d the principles of prostheti cs and orthotics to develop many innovative systems of fracture bracing for both the lower a nd upper extremity.
19 70
Moo ney
U.S. surgeon who utilized a combination of plaster cast and kne e braces at R ancho Lo s Amigo s Ho spit a l in Lo s Angele s to treat fractures of the distal femur an d prox imal tibia en co uragin g func tio nal weigh tb earing.
19 36
Cru tch field
Developed skull tongs to permit skeletal traction for cervical spine fra ctu re s.
19 59
Perry
Ra ncho Lo s Amigos surgeon wh o introdu ce d the ha lo fo r skeletal tr action an d f ixat io n of s pina l frac tur es an d dislo ca tions.
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19 73
Gardne r
A n euro su rgeon wh o developed the principle o f sprin g-l oade d po ints f or sku ll tongs to sim plif y a pplic ation o f acute trac ti on for cervica l in juries.
Modi fied fro m P eltier L. Fractures: a history and iconogra phy of their treatment. Sa n F ra ncisco: No rm an Publ ishing, 1990.
Ski n a nd ske letal tract io n fo r fractu re imm o bilizatio n only bec ame acc epted for gene ra l u se durin g the p ast 10 0 years ba sed o n th e tech niques of Bu ck, Kirschner, Ste inman n, a nd others . Th us, in con tra st to biolo gic processes of repair that evolved over eons to allow healing in response to fracture fragmen t motio n, our mechan ical me th ods of fracture immo biliz atio n have develo ped in relatively a few seconds on the evolution ary time scale. Th e An glo- Am erican c oncept during the pas t centu ry, as advoca te d by H. Owe n Th omas, R obert Jo nes, a nd Wats o n Jo nes, wa s tha t con tin uo us, un interrupted rest an d immo bilizatio n (with out a llow ing fractur e motio n) were essential for fractur e unio n. Th is co ncept wa s based particularly on e xperience in tre ating th e th en-commo n pro blems o f tuber culo sis an d other in fectio ns o f bon e. In co ntr ast, the prevail ing co ncept i n th e E uropea n co ntine nt f ostered by Luca s-Ch amp io nnie re w as th at life is motion. Active, early restoration of muscle and joint fun ction with cl osed, or if n ecessary, operative te ch niqu es, bec ame the goal o f Euro pean follo wers of L ucas-Cha mpionnie re a nd others. Th e co nsequen ce has bee n th at E uropea n su rgeon s such as Ku nts ch er, as well as th e AO grou p, h ave led the devel opmen t of e ffec tiv e o per ative fixa ti on tec hniqu es . Man y o f the i nnovatio ns from th e An glo-Am erican sch ool have, until rec ently, be en directe d at no nope ra tive tech nique s, particularly casting and bracing of fr actur es.
SELECTION OF FRACTURES FOR NONOPERATIVE TREATMENT AND ACCEPTABILITY OF REDUCTION

E ver y stude nt ph ysicia n learnin g the art of closed, no no per ative ma nage ment first des ires str aigh tfo rw ard gu ideline s to decide w hat fractur es to trea t nono per atively and wha t is an ac ce ptable re ducti on. Perhaps the first rule sh ou ld be that virtually every fracture can be treate d and has been treate d nonoperatively. The question in regard to selecting treatme nt should be: Why ca n't this p art icular fractur e be tr ea te d nono per atively? As our techniqu es, surgic al skills, a nd e ager ness to trea t fra ctur es operatively increase, th e a nswers to this key qu estion can be m ultiple. Ma ny patients are more co mforta ble w ith o perative tre atment and return to relative i ndepen dent fun ction more readily ( 17). This is pa rti cu larly tru e for patients with mu ltiple fractures or systemic i nju rie s from vio len t mec han isms of th e type seen in many tr auma centers. Ho wever, most pa tie nts su sta in an isolated fra ctu re tha t do es no t usu ally requir e th e high po wer ed care of trau ma centers. These isolated fra ctu re s may do just as well with nonoperative management withou t the risk o f surgery. Ju st as th e frequen cy of ma ny procedur es su ch a s lamin ectomies and total jo int re plac ements v aries with the con ce ntr ation an d ph iloso phy of surgeo ns (1 8), the indica tio ns for operative treatment of fractures often depen d primari ly on th e train ing and biases of tha t community's fracture surgeon s. However, a s Kelle r an d co-workers (19) have emph asized, physicians ca nno t assume that their outco mes will be th e sa me as othe rs and therefore they need to evalu ate th eir own results. Th e u su al criteria for se lecti ng trea tmen t an d ev alua tin g o utcome tend to be ba se d o n th e ra diograph ic characte ristics of the fra cture (20). Unfortunately, cl assi fication of fra ctu res and outcome assessments that rely on these criteria ca n be misleading and vary from one observer to the n ext (21, 22). Also, the concept that less than anatomi c align ment of the fra ctu re leads inevita bly to ma luni on, art hritis, a nd u nsatisfacto ry f unctio n has p ro ven, in genera l, to be incorrect in lo ng- term studi es (23 ,2 4,2 5,26 ,27,2 8). Studie s ha ve sho wn that so me sh orteni ng a nd limited frac tur e a ngul ation do no t impa ir f unctio n and may a ctu ally speed u p frac tur e h ealin g a nd resto ra tion o f bone strength (27, 2 9). However, failure to achi eve pe rfect reduction natu ra lly crea te s a question in the
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mi nd of an y studen t or patien t who lo oks at a n x-ra y of a frac tur e wit h sli ght sho rt ening or ove rridin g o f f ra gm ents a nd feels that an uns atisfactory re su lt is being accept ed. The an sw er to these concer n s i s t hat it is the a ppearan ce o f the limb, no t the x-ray, th at co unts ( see Figs. 5-2, 5 -3, 5 -4). T he n atural processes of repair can remodel and restore normal anatomy qu ite effe ctively but not if they a re impe ded by malpo si tio ned inter n al or exte rn al fixa ti on devices (F ig. 5 -1 ). This is even more i mportant for children wi th gro wth potential where remodeling permits a wider range of what ca n b e co nsidered an accept able reduc tio n (30 ). Th e key determina nt of the acceptability of redu ction is that the patient's fractured limb looks norma l clin ically. If one inspect s P.1 50 a limb, it is usual ly possibl e to det ermine if it is an gulated, malro ta ted, or sho rtened (F ig. 5 -2 ). R adio graphs are mo st usef ul in evalu ating th e redu cti on of frac tur es i nvolv ing j oin t surf aces. Also, ra diograph s are usef ul in determining that the re duc tion ha s restored the join ts abo ve and below the fracture to a n ormal relationship. It is ax iomatic th at a n x-ra y of any fracture prior to reduction sh oul d inclu de th e joints proximal an d distal. Th e sa me rule holds in o rder to eva luate the reduction o f a fra ctu re ade quately. Jo int alignme nt is bes t assessed on a sin gle x-ray . Fo r exa mple, th e tibia l frac tur e particularly requir es th at th e x-ray show bo th the kne e a nd a nkle, obtain ed, if n ecessary, by p lacing th e l imb dia gona lly a cross the cassette . This view sh oul d con firm a sa tisfactory relationship w ith th e knee and ankle despite th e presen ce o f slight frac ture overriding o r sho rten ing.
FIGURE 5 -1 This dista l femora l fracture de monstrates that loose internal fixation may impede processes of f ra ctu re repa ir an d lea d to bo ne resorption an d a bo ne gap ra ther th an bon e formatio n a nd fractur e un ion.
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FIGURE 5 -2 A. This pa tient's leg dem o nstra tes an in te rnal rotatio n and varus angu lation 1 yea r after h er fra ctu red tibia wa s con sidered to have healed satisfa ctorily by x-ray. The distal torsio nal an gulat io n of the limb ca used th e pa ti ent di sco mfo rt fro m wa lking on the lateral aspect of he r inve rted fo ot. In redu cin g a fra ctu re the clini ca l three - dimen sion al a ppearan ce o f limb align me nt is a pri ma ry determ in ant of an acc eptable r edu ction. B. A n te ro po st er io r and la te ra l x -rays of this patient's heale d fra ctu re we re c on sidered to show sa ti sfactory ali gnm ent but u nfortuna tely the two -dim e nsion al x-r ay images did n ot sh ow the thr eedim en sio na l to rsio na l malu nio n th at wa s cau sin g the patie nt to inve rt her foot and produ ce ver y pain fu l symptoms with weightbeari ng.
Sli ght limb sho rten ing is desirable with closed fra ctu re m an agemen t, and in fa ct the cre ation o f a frac tur e gap by un sta ble i nternal fi xation techn iques has be en one o f the p rime avo idable cau se s of n onunio n in th is a utho r's review of 2 00 oss eo us h ealin g pro blem s (11 ) (Fig. 5-1). Fractu re sho rtenin g or overriding promotes a stronger callus with a w ider surface a rea. Th is is a classic demonstration of W ol ff's law that bo ne responds to th e need for it an d is co nsistent wit h th e wa y in wh ich bo ne a nd soft tis su es h eal in re spo ns e to applied stresses (3 1, 3 2) (F ig. 5 -3). In summary, nonope ra tive treatment can be usua lly selected for most fractures despite significan t a nd enthu si asti c advo cacy for operative tr eatmen t of a ll frac tur es. The tr eatmen t cho se n sho uld be ta ilored to the needs of the patient rather than the patient being fitte d to the needs of the thera py. Th e ma in de te rmi nan t of a n acce ptable clo sed redu cti on is t ha t the limb appears norma l by clinic al e valua tion to allow prompt restora tion of fun ction with h ealin g. Restoration o f length of th e fractured l imb is more important in the weightbea ri ng bo nes of the lo wer li mb than it is in the upper limb. H oweve r, even in weigh tbe aring bones slight s horten ing from s ome fracture ov errid ing i s prefera ble to th e creatio n of f rac tu re ga ps by unstable intern al fixat io n te ch nique s (33 ). Co nsequen tl y, to a nswer th e qu estion o f what is an accept abl e redu ctio n, one mus t fo cu s on the appe aranc e an d fun ctio n of the patien t's fra ctu re d lim b and no t m er ely on the x-ray (Figs. 5- 2 an d 5 -3).
OPTIONS IN NONOPERATIVE MANAGEMENT OF FRACTURES

Th e ba si c metho ds of n on opera tive frac tu re ma nagem e nt in clu de re duc tion b y tra ctio n and ma nipu lation o f the fractur e follow ed by immobil ization o f th e re duc ed frac tur e using ca sts, spli nts , b ra ce s, or othe r tec hni ques . Ho wever, a n umb er of commo n frac tur es re quir e no reduc tio n a nd may b e effectivel y treated by pro viding pain relief , a m ini ma l pe ri od of immo bilizatio n, a nd pro mpt re sto ration o f fun cti on. Pai n rel ief is best accomplished using lo ca l meth ods i ncluding the tec hniqu e of re st, ice , compres sio n, and e levatio n (RICE ). The patient shou ld a lso be prescr ibed su ffic ient a nal gesi cs to re lieve th e a cute pa in of the fra ctu re, wh ich c an be quite sever e. P.1 51
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FIGURE 5 -3 This humera l sha ft fractur e was trea te d with a fractur e brace and hea led in bayo net appo si tio n, primarily b y form ing externa l callu s. The m ass ive a mou nt of new bon e formed on the circu mferen ce o f the h umerus increased the structura l mo ment of ine rtia, wh ich is proportionate to the ra dius to its 4th power (R4). An atomic re alignme nt is not the si ne qua no n of a n accept able re duc tion.
A whole variety of fa ctors in flue nce th e selection of treatment options. For many common fractures, a n obje ctive an alysis o f ris ks an d ben efits will strongly favo r nono perative treatment (1 1, 34). Th is is e spe ci ally tru e for fractures th at ca n be effectively and safely treated without reduction a s illustrated b y the follo wing examples.
UPPER EXTREMITY FRACTURES COMMONLY TREATED NONOPERATIVELY WITHOUT MANIPULATIVE REDUCTION Clavicle Fracture
C lavicle fra ctu re s are ver y co mm on an d archa eol ogic skel etal rema ins sh ow a high frequ ency of these fractures su sta ined by prehistoric man that he aled withou t ben efit of orth opa edic treatment (35). Clavicle fracture in the child heals promptly when splinted in a figure-of-8 harness for 2 to 3 weeks. In t he adul t, the cl avic le fractur e is dif feren t. Of te n i t is the result of a vio lent inju ry, which c an co mm inute an d displac e the fractur e fra gm ents signi fican tl y. In a r evie w of the lon g-ter m co nseque nces o f c lavicle fractur es (36) , we foun d the fre quency of n on unio n to be abo ut th e sa me a s o ther fractur es (3% to 5 %) . Splin tin g of the adult 's fractur ed clavicle wit h a f igur e-of-8 harne ss is o fte n in effec tive and unco mfo rta ble. No noperative ma nage ment ca n o ften be acc omplish ed best by su pporting the weight of the arm in a slin g a nd swa th to prevent downward pull on the lateral fragment. Usua lly sa tisfactory clinical align ment can be achi eved. However, persi stent displacemen t o f the adul t's cl avic le fractur e c an lead to malun ion an d pro lon g sym ptoms from tho ra cic outlet compressi on (36) (Fig. 5 -4 ). Limb th reatening ischemia from compression o f th e su bclavian artery ma y dev elop long a fter th e displa ce d clavicle fra ctu re is heale d (37 ). Als o, u nrecogn ized su bcl avian v ein th rombo si s may lead to re peated pulm o nary emboli an d even f atal pulm o nary failure (the Pa getVon Sch roetter syndrome) (3 8). Fractures of the lateral third of the clavicle, although not as commo n a s thos e of the middle th ird, ca n presen t dif ficul tie s of ma nage ment. Ope ra tive fixat io n has been as sociat ed wit h c omplicatio ns i ncludin g infection , failure of fixatio n, and per sisten t nonu nio n (3 9). Ro bins o n a nd Cairn s (40) have
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d emonstrated successful results with nonoperative tre atment of mo st displaced l ateral fractures of th e cla vicl e, particula rly, in m iddle age and elderly patien ts. Th ey evalua ted o ver 1 00 patien ts so trea te d by sling immobiliza ti on an d early rang e o f motio n th erapy who usua lly di sca rde d the s ling by 2 w eeks a fter th e in jury. Th is proto col resulted in an initial 37 % n on unio n rat e, a nd th ese n onu nio ns w ere mo stl y asymptoma tic. Onl y 11 % of the patien ts required surgery for their non uni ons. Th e a utho rs f elt tha t an asymp to ma tic fibr ous unio n or no nuni on af ter a dis plac ed lateral c lavicle fractur e ma y be an alo gous to a pa in free dis placed acromio clavicula r separatio n. Many of these lateral clavicle fractures, which can be difficult to fix operatively , may be better trea te d by sling imm obiliza ti on an d early rang e of motio n th erapy. Th e metho d is usua lly qu ite a cce pta ble fo r the m ajority of fractures in middle- aged and elder ly individu als. Surgic a l re construction can be reserved for the mi nority of usu ally you nger patients with persistent discom fort o r sign ifican t disruptio n of the shou lder su spe nsory co mplex.
Fractures of the Scapula

Fractures of the sca pula usually re su lt from a severe direct injury to th e posterior aspect of th e sh oul der, an d al mo st al l are associa te d wit h rib fractur es, pu lmon ary c o ntus io n, pn eumo th orax , or h emopn eumo thora x (41 , 42). They may be a sso ciated w ith va scu lar i njurie s or inju ries to t he brachia l p lexus and th ese a sso ciated problems sh ould be carefu lly e valua te d and treated prior to tre atment of th e fracture. Be ca use of the associate d inj uries, th e u su al treatment of a sca pula fra ctu re is bed rest, a pplication o f ic e, a nd ana lgesics. As t he patien t bec omes amb ul atory, th e limb is sup ported i n a sling an d swath w ith th e a rm supported fi rmly against the chest P.1 52 w all. Th e wra p is us ually neces sary fo r o nly 2 to 3 w eeks, after wh ic h th e pa tie nt can slo wly be gin sh oul der mo tio n and st rengthen ing exercis es.
FIGURE 5 -4 A. This x-ray sho ws the significant displ acement th at ca n o ccur pa rticul arly in t he adu lt's fra ctu re d clavicle whe n th e we ight of the arm pu lls the latera l fra gment downward. B . This fracture healed wi th o verriding of the fra gments and com pressi on of the thoracic outlet particularly wh en th e a rm wa s eleva te d. Symptoms persisted for 10 years until th e ma lunion was corrected su rgica lly.
Intr a art icular gleno id frac tur es can u su ally be tr ea te d nono per atively unl ess there is significant d ispla cement of fra ctu re fragments or d islocatio n o f the jo int. Frac tur es o f the scap ula neck when a ssoc iated with a fractured clavicle a s well as other inj uries ma y require reduction or e ven operative fixat io n to pre vent dro opin g of the sh ou lder a nd w eakne ss of sho ulder mus cles ( 43 , 4 4). Ho wever, they usually can be red uced by lateral traction for a period of 1 to 2 weeks in bed with the patient in th e supi ne position ( 45 , 46) (Fi g. 5-5). Edwards and co-aut h ors (47 ) ha ve fou nd th at n onoper ative treatme nt of floating shoulder inju ries, especially those with less th an 5 mm of fracture displacemen t, ca n a chieve satisfactory results th at a re probably equal or superior to those reported with operati ve treatme nt. The method tha t these au th ors recommend for the relativel y undisplaced fractures is the u se of a shoulder immo bilizer or a s lin g for a perio d of 3 to 8 weeks . Physic al therapy to r egain sh oul der mo tio n is prescr ibed as so on as th e asso ciated i nju rie s allo w, u sually within t he first 2
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w eeks.
FIGURE 5 -5 Fra ctu res o f the cla vic le a nd sc apu la may requ ire olecrano n pin tra cti on as illu str ated here, particula rly for th e head inju re d patie nt. The pin is in se rted thr o ugh the ulna r sha ft distal to the olecran on , takin g care to avo id the uln ar n erve. T he forearm and ha nd a re supporte d by sk in traction. However, for mo st fractures of the clavicle an d scapul a, treatment with a shou lder im mo biliz in g harnes s or sling an d swathe is usually ef fective.
Proximal Humeral Fractures

A number of investigators have demonstrated that there is little evide nce th at operative treatment of 2 o r 3 pa rt fractur es confers ben efi t on t he usu al e lderly pa ti ent w ho s ustains this in jury. Th e u sual 2 or 3 part fracture of the surgical neck of the humerus in an osteoporotic elderly patient can be co nsis tent ly and effec tively tre ated by suppo rt in a sli ng, until i nitial sympto ms subside (48, 49 ). E arly gentle range of shoulder motion at 1 to 2 wee ks, followed by progressively more vigorous e xercise at 3 to 5 w eeks, can reliably lea d to fractu re u nion and re storation o f satisfactory function w ithou t ne cessarily achi eving ana to mic r edu ctio n of the se fra ctures ( Fig. 5-6). C linica l stability and u nio n of the fra ctu re usu ally pre ce des radio graphi c uni on by seve ra l w eeks (50 ). F rac tur e of the proxi mal h umerus is o ften associa te d with a temp orary inf erior subluxa tion o f th e head due to hemorrhage into the joint or the loss of static rotator cuff muscle support. It also may be d ue to lo ss o f negative intra- art icul ar pressure, whic h resists gravit y forces and no rma lly h olds th e h umer al he ad in a rtic ul ation with the gleno id (5 1, 52). Th is pseudo subluxa tion dis appea rs with act ive ra nge of mo tion an d the initia l healin g of th e ca psu le (5 3) (Fig . 5-7). In c on tra st to inf erior su bluxa tio n, whic h is tem po rar y, a super io r migrat io n of t he hu meral head a fter a frac tur e usual ly P.1 53 i ndic ates l oss o f rotato r cuf f fun cti on an d the need for oper ative repair (54) ( F ig. 5 -8). Superio r mi gration o f th e humeral hea d results fro m upwa rd pul l o f the deltoid mus cle uno pposed by the ro tator cuff f orces, w hich no rma lly ma intain the hu meral h ead again st the gleno id during sh ou lder a bduction .
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FIGURE 5 -6 A. I nitial x-ra y sho ws a pro nounced disp lacement of the hu meral su rgica l n eck fra ctu re resul tin g from an interna l to rsio na l mec ha nism. B . The patient was trea ted by allo wing early externa l rotation al e xercise s of th e shoulder. A satisfactory ca llus formed and the fra ctu re he aled wit h sa ti sfactory, but n ona nato mic, ali gnm ent as sho wn on t he se x- rays 1 2 weeks a fter inj ury. C . The cl inical pho to graph o f this patie nt a t 12 wee ks po stf rac tu re sho ws th e ran ge o f motion possible when the emphasis was placed on function al early exercises while the fractu re was hea ling ra ther th an waitin g for th e fracture to h eal radio graphically bef ore allo wing function al exercises.
C losed reduc tio n o f surgical neck fractur es is usua lly u nne ce ssa ry as well as in effective. The compulsion to redu ce these fra ctu re s an atomically is difficult bu t importa nt to repress (55). One sh oul d rathe r allo w th e normal forc es o f s hou lder mo tion an d mus cle function t o align the frac tu re a nd anticipate that some degree of remo deling will occur. Furthermo re, over forceful manipulation , p articularly if resisted by tigh t muscles, ca n co mpletely displace th e h umeral hea d fra gment (5 6, 57). Th e sho ulde r is the mo st mobile joint in th e bo dy a nd it dem a nds consid erable fle xibility to mai ntain i ts nea r glo bal ra nge of mo ti on. Theref ore, manag e ment of fra ctu re s abo ut th e sho ulde r sho uld i ncorpora te a pro gra m of early exercises to
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P.1 54 ma intain motion. Otherwise the shou lder capsu le can become progressi vely stiffer (5 8, 59).
FIGURE 5 -7 A frac tur e of the proxi mal h umerus tre ated w ith pro lon ged immo bilizatio n may dem o nstr ate in ferio r subl uxatio n o f the hea d of the h umerus if the patient does no t actively exercise the shoulder. This is due to a combination of loss of negative pressure within the joint as well as lo ss o f rotator cuff a nd deltoid mus cle su pport. It can be ov er come b y all owin g the patien t to exerc ise actively.
To p reve nt this rat her co mm on p ro blem, wh ich i s essentiall y an a dduction c on tra ctu re o f th e gl eno h umeral caps ule , it is essential to incorpo rat e a pro gram of early pas sive range of mo tion exercises a s soon as th e fracture sh ows early clin ical sta bility. W aiting for compl ete radio graph ic hea ling for 6 to 8 we eks is o ne of th e ma in ca uses o f no nun ion somet ime s att ributed to no no per ative treatme nt. Persistent immobilization of th e shoulder may ca use th e fracture gap to wide n du e to th e pu ll of the dead weight of the arm and the lack of mus cle functi on impac ting the fractur e fragmen ts. Prol onge d immo bilizatio n o f the fracture also lea ds to lo ss of functio nal m otio n, p articu larly abduction a nd external rotation of the shoulder. By 2 weeks, gra vity-a ssisted exercises w ith circumd u ctio n or pend ulu m mo tions shou ld be en co urage d. These can progress by 4 to 6 weeks to pa ssive str etch ing of the sho ulder in abduction a nd e xte rn al rotatio n (59) . In doin g this the patient b ra ce s the sca pula aga inst the wal l and attemp ts to brin g the ir clasped han ds up behin d the he ad. Th e sho ulde rs are th en abduct ed and externa lly ro ta ted , usu ally with the a ssist an ce o f a family me mber, un ti l the indiv idual can bring both elbo ws back to the w all. Th is exerc ise may in itially be so mewha t pain ful, but by 8 to 1 0 w eeks it is usu ally possible to a chieve close to full abdu ction. In u sing th ese e xercises for most fractures of the surgical neck of the h umerus a nd basing progress to ward heal ing on clinic al r ather than radio graphi c criteri a, one can minimize lon g-ter m consequ ences o f the inj ury wh ile encou raging hea ling of the fra ctu re (50 ).
Humeral Shaft Fractures

Fractures of the hume ra l sh aft provide excellen t demonstration s of how well-intention ed bu t mi sdirected efforts at fracture reduction and immob ilization can be detrimental to healing (6 0). In the 1 93 0s a nd 1940s, w hen mana gem ent of the hu meral sh aft fra ctu re emph asized tech niques such as a bduction airplan e splints or shoulde r spica ca sts, th e h umeral fractu re became a prime ca ndidate for n onu nio n. As th e failu re o f these approa ch es beca me evide nt a nd frac tur e su rgeon s b ecame a ware that h umeral fra ctu res he al w ith min imal immobiliza tion, techniqu es such as han ging ca sts improved results (61 ). Un fortu nately, they ofte n ca use pa tient di sco mfo rt an d ha ve a tend ency to cau se frac tur e a ngul ation an d distr action du e to the assumed necessity o f imm obi lizing th e e lbow. Su bsequen tly, in the last two to three dec ades Sarmiento an d co lleagu es (28,6 2,6 3) h ave
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d emonstrated that humeral fractu re bra ce s, by a llowing el bow m otion, can realign the a xis of the e lbow joint, redu ce the fra cture, an d pro mote heali ng. Thi s techniqu e has sign ifican tly im pro ved re su lts to the point that the humeral shaft fracture treated in this way rarely fail s to heal . Fra ctu re b race treatmen t empha siz es reduc tio n by the fo rce o f gravit y a nd fun cti ona l mu scle ac tivit y. A wellv ascu larized mus cle e nvelo pe surro unds the humeral s ha ft. Thi s envel ope helps to co ntr ol the a lignment of th e fracture in th e brace and stimulate s callu s formation . Isometric mu scle con tra cti on i n th e fracture bra ce do es not deform the fracture; ra ther, it aligns it. Muscle fu nction and elbow mot ion a ctu ally se rve to align the hu meral fracture by restori ng th e a xis of e lbow m otion to a n ormal re lation sh ip w ith t he hu meral sh aft (Fig. 5-9). Ini tia lly, th e fracture sh ould be imm obilize d to make the patient comf ortable, prefe ra bly wi th a Ve lpeau type o f dressing. Th is inc lu des an a xillary pad, a slin g to suppo rt the weight of the arm a gain st the patient's che st, and a ci rcu mferen tia l wra p aro und the chest. The use of gutter splin ts for h umeral shaft fractures should generally be discou ra ged since they tend to be u ncomf ortabl e for th e pa tient and angu late th e fractur e (Fig. 5 -9) . Th e u su al tre atment i s Velpeau im mo biliz atio n until t he sw elling subsides by 1 to 2 weeks, wh en the frac tur e brace ma y be applie d. This i s usua lly a po lypropyle ne p re fabricated brace, whic h wraps a rou nd th e ar m while al lowin g elbo w flexio n and extensio n. Du rin g the in iti al w eek o r t wo a fter a pplicatio n o f the brace, the patie nt gen erally requir es sli ng sup port of the arm . Subsequ ently, active flexio n and ext ensio n of the elbo w is allo wed to e ncou ra ge bo th alignme nt of the fractur e and to p ro mote a ca llus re spo nse. By 1 0 to 12 weeks th ere is usua lly adequate clinical an d radio graphi c h ealin g to discard th e fracture bra ce.
Fractures of the Head of the Radius

Th e co mm on un displ aced frac tur es o f the radial hea d or ne ck can be trea ted by aspir atio n o f the h emarthrosi s followed by t empora ry sling support. Holdsworth a nd co -w orkers (64) have sh own the b enef it of aspirating the elbow an d in stilli ng a lo cal P.1 55 a nesthetic to re lieve th e a cu te pa in and perm it earl y range of m otion. Active flexion an d exten si on of th e el bow can be st art ed as so on as th e acute swel ling and pain subs ide usual ly with in 2 to 3 da ys. P rolo nged elbo w immo bilizatio n in a slin g will inh ibit retu rn ing motio n pa rticu larly to f ull extensio n (65).
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FIGURE 5 -8 A. A pa ti ent in h is 40 s s us tain ed th is fra ctu re dis lo ca tion o f the sh oulde r wit h evide nce of rotator cuff disruption . The shou lder w as reduce d but the rotator cuff was not repaire d. B. X- rays 3 m on th s after the dislo ca tion s ho w supe rio r migra ti on of t h e humeral hea d up toward the acromion as a resul t of loss of the rotator cuff.
Slight displacement of these fractures can occur and block elbow motion. To determine if this is a p ro blem , th e fracture hemat o ma sh ould b e aspirated and a local an esth etic inj ected (66 , 67). Elbo w ra nge of mo tion can then be evalu ated to determ in e if th e rad ial head fra cture blo cks either flexio n/extensio n or su pinatio n/pron ation . If there is eviden ce of a mechan ica l blo ck to elbo w motion th e fract ure fragmen t should be ei th er excised or red uced and fixed op eratively (6 8). If it is decided th at the fragment is no t a n o bstruction to motio n, the elbo w ca n b e immo bilized te mporarily in a sli ng fo r 48 h ours while ice i s applied to the elbow . Subs equ ently, w hen the pain subs ides, the patie nt b egins active f orearm rotatio n and flexion /exten sion exer cis es of t he elbow . Nearly full ra nge of mo tion s ho uld retur n by 4 to 6 weeks. Nonu nio n of no no per atively tre ated frac tur es o f the radial he ad a re ra re . Even when the fracture line is still apparent months after th e injury, heal ing ma y still occur. O per ative trea tm ent o f s uch apparen t dela yed u nio ns o r no nu nio ns is ra rely n ecessa ry since the p atient is usua lly a symptomat ic. Bro ber g a nd Mo rr ey (69 ) ha ve sho wn that for frac tur es tha t remain symptomatic, delayed ex cision of the f ra ctu red radi al h ead can achieve satisfa ctory resul ts. Th is was tru e in thei r experien ce with 21 pa tients who had excision o f the ra dial head from 1 mo nth to more than 20 years after fracture.
Isolated Fractures of the Ulna

Li ke the fra ctu re o f the cla vic le th e iso lated fractur e of th e ulna has been foun d to be amon g the commonest in skeletal remains of prehistoric ma n (35) . The classic mecha nism of this injury is a d ire ct blow to the forearm oc curring when the forearm is raised to protect the head. Mo st com mon ly th e iso lated ulna r fra ctu re is relatively undi spla ced. T he isola ted frac tur e usually doe s no t present w ith mo re th an 10 to 20 deg ree s of a ngula tion an d 50% dis plac ement and can be trea ted wi th ou t re duc ti on. P aradoxically, it seems th at th e more one tri es to immobilize the isolated u lnar fra cture in a lon g a rm ca st, th e mo re l ikely i t is tha t the fra ctu re will be slow to heal o r not he al (7 0). F unctio nal bracing as d evelope d by Sar miento an d co -workers (63 , 7 1), ha s yielde d sur prisingly goo d fractur e hea ling and fun ctio na l results, o ften bet ter th an even o perative te ch nique s (73). Th e rea son for the se excelle nt re su lts is u ncertain but it P.1 56 P.1 57
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a ppears that the m ethod i mproves circula tion an d promotes early production o f external c allus. This re su lts fro m a n e mphasis o n funct ional mu scle activity encou raged by al lowin g elbo w and wrist mo tion .
FIGURE 5 -9 A. T his frac tur e of the hu meral sh aft was te mp orarily splinted wit h a gutter splint that actually ma de th e pa tient uncomfortable due to the plaster rubbi ng i n th e axilla. It also pro duced th e unacc eptable an gulatio n evident here. B. The patie nt was transferred to a fra ctu re brace an d sling wit hin the first week after inj ury. Active flexio n and ext ensio n of the elbo w pe rmi tted gravit y and mus cle fun ctio n to align the fractur e and restore t he axis of elbo w m o tio n t o no rm a l. C. Early fractur e un ion was eviden t at 8 w eeks wh en t he patient had close to no rm al motio n o f the elbo w an d sho ulde r. D. Frac tur es of distal hume ru s treated in a hangi ng arm cas t witho ut allo wing elbow motio n may heal with an intern al ro tation -va rus a ngula tion. E. A h umer al f ra cture brac e or sleeve is effective in align ing th e humer al s haft or distal humera l fra ctu re thro ugh function al motio n of the elbow . This fractur e sleeve may be appl ied to the arm in the early phas es of h ealin g as the pain and swellin g fro m th e fractur e su bsi de. F lexion a nd exten sio n restore the n ormal align ment of the elbo w axis of motion . (Modif ied from Conn olly J. Fra ctu res an d dislocation s. Closed ma nagemen t. Philadelph ia: W B Sa unders, 1 995, with permission .)
Th e frac ture sh oul d be im mobili ze d wit h a splint or c a st fo r the fi rst 3 to 5 da ys un ti l the swellin g an d d isco mfort subside. Su bsequen tly , a prefa bri ca ted brace or c ast can be applied to support th e fracture but a llow the elbow and w rist to function freel y (Fig. 5-10 ). T he fracture brace h as Vel cro straps to permit tightening a s the swelling subsides. It may be removed for personal h ygiene. In eval uating the progress of hea ling, most ulnar fractur es heal clinic a lly (as evidenc ed by a bs ence of p ain either on direct pa lpitation o r forearm rotation), severa l weeks or even sevral month s before ra diograph ic h ealing is co mplete. Ho wever, fractures th at a chieve clinical un ion even tually hea l ra diograph ically. Th erefore, prolonged immobilization preventin g the patien t from return ing to w ork u ntil th ere is comp lete r adio graphic unio n is bo th unnecessary and un des irable for mo st patients (73).
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FIGURE 5 -10 A fracture brace can be applied to the fractured ulna by 3 to 5 days when swellin g and di sco mfort hav e subs ided. This sho uld perm it free elbow, wris t, an d finger motio n wh ich in turn en co urage s early clinical un ion of th e fracture. (Mo dified fro m C onnoll y J. Fra ctu res an d dislocation s. Closed ma nagemen t. Philadelph ia: W B Sa unders, 1 995, with permission .)
Fractures of the Carpal Scaphoid

U ndispla ce d fra ctu res of th e mid scaphoid occur co mmonly and often are not even dia gnosed (74). Asympto matic un unit ed fra ctu res o f the scaph oid have been repo rte d in bo xer s as well as in o ther i ndividua ls wh o use th eir h ands for arduo us work (75,76 ,77 ). T he usual fra ctu re lin e tha t run s tra nsversely or slightly obl iquely across the longitudi nal axis of the scaphoid tends to be compresse d b y the surrounding muscles of the fingers (Fig. 5-11). This type of fracture is stable and will heal q uite qu ickly and co nsistently with closed nonoperative treatment (78). Although the re is a tren d tow ard internal screw f ixation o f the sca phoi d fra ctu re, a recent ana lysi s (7 9) sea rch ing f or eviden ce -ba se d data ha s f oun d n o si gnifi ca nt ben efi t fro m o per ative fixa tion fo r th e comm on un displ aced mid third sca phoid fra ctu re. Interna l fixatio n do es res u lt in a signif ica ntly e arlier re tu rn to work compared w ith castin g. However, casting and in te rn al fixation do not differ sign ificantly in clinica lly relevant outcomes such as gri p strength, range of motion , or risk of n on unio n (79) . Th e u ndisplaced scaphoid fractu re does not re quire re duction P.1 58 a nd ca n be immo bilized if seen acutely in a coope ra tive pa tient u sing a sho rt a rm thum b spic a cast extending from below the elbow to the metacarpal heads. A position of w rist dorsiflexion and radial d eviatio n pe rmits co mp ression of th e tran sv erse scapho id frac tur e and is the po sitio n of cho ice for i mmobiliza tio n. The th umb s h oul d be in a gra spi ng po sition wit h the cast ext en ding across the i nter phala ngea l jo int of the thu mb ( 80 , 81 ). I f the scaph oid fra ctu re is di agno sed a week o r two af ter i nju ry or occurs i n th e pa tie nt wh o m ay not be o ver ly co ope rat ive, a lo ng arm t hu mb s pic a cast is p re ferable to the short arm thu mb spic a c ast an d ma y decrease the risk o f delayed or no nun ion ( 82 ).
FIGURE 5 -11 A. A typical fracture of the carpal scaphoid occurs as the result of a fall on the outstretche d ha nd producing forcefu l dorsiflexion of the wrist. B . An undispla ced scapho id fra cture do es n ot usually require reductio n and ca n be imm o biliz ed by radia l dev iation o f the wrist. U lnar deviatio n te nds t o o pen up th e fr actur e sit e an d sho uld be a voided. (Mo dif ied f rom Conn olly J. Fra ctu re s an d dislo ca tion s. Clo sed man agemen t. Ph iladelph ia: W B Sau nders, 1 995,
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with perm iss ion.)
The cast should be inspected every 2 weeks, and if it becomes loose, a new snugly fitting cast should b e ap p lied. A t t h e en d o f 8 weeks the ca st is rem o ved a nd th e pa ti ent e valua te d c aref ully. If th e wris t i s p ain free a nd a rea sona ble ra nge of mo tio n is evi dent, the wris t c an be protec ted in a sim ple wris t splin t. If the patient has persi stent discomfort, we akness, pain, or ten derness i n th e snuff box region, th e cast is reapp li ed for 4 to 6 mo re we eks . In general, cast immo bilizatio n sh ould be contin ued for n o lon ger than 3 months. If th e fracture i s sti ll clin ica lly symptomatic after th is time, treatment with i nternal fi xation a nd bo ne graft sho uld be co nsidered (7 8,81 ,83,8 4). Th e str on ges t case again st pes simism in mana ging the broken scapho id non operative ly wa s that p resented in 1961 by P. S. London (85) in a review of 300 cases from the Birmingham accident h ospit al. Lon don's appr oach w as at varian ce with t he pes simis tic think ing of his tim e, wh ich s till see ms to pr evail today . Usin g the s imple cast imm obil ization techn ique describe d abo ve, 90% to 95 % of scaphoid fractures (in cluding those not treated for 3 to 4 weeks after inj ury) healed. As wit h many othe r fra ctu re s, clinic al eviden ce o f unio n of th e scapho id fractur e precedes ra diograph ic evid ence. The re is no con clu sive e vidence th at pro longed i mmobiliza tio n does in fa ct p re vent n on unio n (84) . Bo ny unio n can occur wit hou t it, a nd fibro us u nion can o ccu r in spit e of it . E ven thou gh the fr acture line is still faintly visible wh en th e pla ste r is disc arded, it u su ally bec omes o blit erat ed during the ensui ng 6 to 1 2 mo nths. Even if f ibrous unio n d evelo ps, it i s not usu ally d isa bling. Th e f ibrou s un ion is most o ften diagn osed on ly a t the time o f some later inju ry, an d these n ew sympto ms o ften subside within a mon th o f plaster immo bilizatio n.
Phalangeal and Metacarpal Fractures

To rsi ona l or twis ting mechan isms ar e fairly commo n causes o f pha lange al and metac arpal fractur es. P ersiste nt ma lrotatio n w ith o ver lappin g o f t he inju re d finger during grasp can impa ir f unctio n of the h and. This de forma tion can be co rr ected not by man ipulative reduc tio n bu t by maintai ning jo int a lignment through fu nction al mo tion . To prevent malrota tion, the preferred method of immobilizin g p hala ngeal fra ctu re s is by buddy P.1 59 ta ping, or splin ting, th e finger to th e adjacen t un inju re d finger (F ig. 5 -1 2). Thi s allo ws o ne to e valua te the rota tio na l a lignment of th e fingers a nd co rr ect an y mal ro tat ion o ver lap by a ctive flexio n a nd ext ensio n o f the fin ger j oints . Am o ng the more diff icult f rac tur e problems a re tho se i nvolv ing th e pro xim al phala nx, th e so -cal led n o-man 's-lan d fract ure, ide ntic al ana to mically to Bunn ell's no-man's- land in t endo n su rgery. Multiple me ta carpal fractur es also provide dif ficul t challe nges t o redu ctio n and fi xation t echn iques. Bu rkhalter, R eyes, a nd La tta ( 23, 86) h ave demonstr ated effect ive alignme nt of these pro blem fractures by ma intain ing maximum fle xion o f th e meta ca rpopha lan geal (MP ) joints an d e ncoura ging early finge r mo tion in this positio n. Bu rk halter has pointed o ut tha t abso lute ana to mic restora ti on of e xtra articular fractures is not n ecessa ry in the han d, bu t early motion is essential to avoid stiffn ess a nd malf unction . Shortening within rea so na ble li mi ts will not r esult in f unctio nal lo ss provided there i s no los s of join t mo tio n. Particula rly of concern is loss of flexion o f th e MP joint and s econd arily los s of mo tion in the interphalangeal j oints. Bu rkhalter points ou t that the major deformities with tra nsverse or oblique fractures include f lexion a nd overriding of the distal fra gment as well as a bnorma l rotation . The key to correcting both of these problems is to place the MP joint in maximum flexion of 70 to 90 degrees. Doing this utilizes the intact dorsal hood as a tension band (Fig. 5-13). The effect of the dorsal tension band is to compress the palmar cortices of the fracture as the finger i s fle xed. The tensio n band produ ced by th e e xte nsor mechani sm is cr itical no t only for vola r cort ical compression but also for reduction of the fracture and stabilization of the MP joint in a flexed p osition . If the extensor tendo n i s destroyed by th e in jury, th is metho d of man agement will b ecome co mp letely inef fective, and interna l stabil ization beco mes ne cessary.
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FIGURE 5 -12 A. A fracture of the phalanx or metacarpal may heal with overlapping fingers if the fra ctu re d digit is no t h eld in pro per ro ta tiona l a lignmen t. B. Th e pref erred me th od of immo biliz ing an is ola ted ph alan geal fracture or metacarpal fra ctu re is b y splint in g the inj ured finger to t h e a djacent fin ger to aid in prope r rotatio nal reali gnm ent of the fra ctu re (buddy tapin g). (Mo difi ed from Connolly J. Fractur es and dis locat io ns. Closed mana gement. Ph iladel phia: W B Sa unders, 1995, with pe rmi ssio n.)
Th e techn ique invo lves first applyi ng a sho rt arm cast with the wrist in 40 degr ee s of e xte nsion . The d ista l pal mar crease shou ld be f re e of padding o r plaster. Aft er the cast h ardens, a w ell-padded d orsal sl ab is added, and as th is plaster hardens, direct pressure over the dista l portion of the p roximal phalanx is used to push the MP joint into 70 to 90 degrees of flexion. After the cast is co mpleted, f lexio n and extensio n of the proxima l inter phala ngeal (PIP) j oin t is e ncou ra ged. The p atient sh ould be inst ructed t o clo se al l fingers simu ltaneo usly without al lowin g o verlappin g. As the swe lling su bsides the cas t is replaced with a n ew one. The key is to maint ai n th e MP jo int flexio n by ma intain ing pressu re o ver t he prox imal ph ala nx (F ig. 5- 1 3). W ith this meth od it is di fficu lt a nd pro bably unn ecessa ry to c heck align me nt by sta ndard x- ra ys b eca use su perimposition of multiple skeletal s tructures in the c ast ma kes assessment quite di fficu lt. O ne or two linear tomo grams may be used i f th ere i s any questio n abou t reductio n. Ho wever, the ma in determ inan t o f the a dequa cy of a lignm en t is c lin ical. Th e a dvantage with this tec h nique is th at w ith th e MP joints flexed almost 90 degrees, no rota ti on occurs unless it is mirrored in the f ingertips. W ith all t he finge rs fle xed sim ul ta neo usly to 9 0 degrees, adjacent digits wit hout fracture will help to d e-rotate th e fractured one. In a ddition , the effect of the extri nsic extensors of the me ta carpal p halangeal joint i s reduced by dorsiflexing the wrist to 45 degrees. Sim i lar mec h anical an alysis a pplies to t he dif ficult fracture of th e pro ximal phala nx, th e so -cal led n oma n's-land fracture. To align this fracture, the MP j oin t is stabilize d in maximu m flexio n. It is this j oin t tha t is capa ble of motio n in mult iple directions includin g ro tation , abdu ctio n, adduc tio n, flexio n, a nd ext ensio n. Ho wever, th e ro tat ion al and abductio n/adductio n mo tion s are elim in ated as the MP j oint is f lexed maxima lly. P.1 60 Th ere a re pitfalls in the close d treatment of a ny fracture, and the method described h ere requires a tte ntion to det ail bo th a cu tely a nd o n follo w-u p. I t al so requ ires will ingness to a bando n the method i f alignme nt is not achiev ed. The m etho d, however, does not reduc e vascularity to th e frac tur e site or p ro duc e additio nal inju ry to tendo ns or join ts that may ca use loss of motio n. As Burkhalt er and Reye s (2 3) po int out, it wo uld be a ho llo w victo ry for th e surgeo n to obtain an a nato mic reduct io n w ith so lid o sseou s un ion but wit h sig nifi ca nt exten sor lag of the PIP jo int.
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FIGURE 5 -13 A. Th e ke y to correc ting fle xion an d o ver riding of pro xim al phala ngeal o r metacarpa l frac tur es is to plac e th e met aca rpo pha lange al (M P) joi nt in maxi mu m f lexio n of 70 to 90 degree s. This u tilizes t he inta ct dors al hood as a t en sio n band. This do rs al ten sion ban d compresses th e palmar cortices of the f ractu re a s the fin ger is flexe d. B. T o maintain t hi s tensio n band effect of t he dorsal m echan ism, the fractur e is trea ted wit h the wrist extende d, an d a splint is appl ied to the do rsa l surfac e o f the fo rearm a nd wris t. Pla ster is mo lded to main tain the MP join ts in m aximum fle xion . To achiev e this , th e pa lm sho uld not be hea vily padd e d. The interpha lange al (IP) join ts are allo wed to f lex and are held in t he p osition o f function . C. Th e splint is incorporated in a short arm ca st, and as th e a cute swel ling su bsides the patien t is e ncoura ged to a ctivel y flex th e fingers . E xtension sho uld be avoide d un til the fracture h eals , by 3 weeks, when the cas t is rem o ved. (Mo difie d f rom C on nol ly J. F rac tur es a nd disloca tions. Close d man agemen t. Ph iladelph ia: W B Sau nders, 1 995, w ith perm iss io n.)
Fifth Metacarpal Fractures

In a class ic clinic a l st udy of the fifth m etac arpal f ra ctures in a c ompen sa ti on clinic popu lation in 1 97 0, Hunter and Co wen (87) pointed ou t the adva ntage of n ot over trea ting th ese frac tur es by v igorous attempts a t closed or ope n redu cti on. My experience h as also been that most of these fractures d o not warran t any method of reduction th at may prolong or c re ate pe rma nent disability. So me sh ortenin g and angul ation o f the fif th m etaca rp al sh aft and neck fractur es are co mpatible wit h e xce llent functi on. A cceptin g up to 40 degree s of palm ar angu lation o f a metacarpal neck fractur e (a nd u p to 20 de gre es in a shaft frac tu re) ha s no t resulted in any function al dis ability in studi ed co mpensatio n popu lation s (87 ). The a bs ence of symptoms from palm a r angulat io n of the metacarpa l i s due to the fac t that th e fift h carpal-met ac arpa l j oint is qu ite mo bile. Th er e is abou t 3 0 de gre es o f mo tion in this jo int a s oppo sed to the carpal -met a ca rpal j oin ts of th e in dex o r lo ng fin ger s, in which th ere is vir tually no m o tion, an d thu s residual an gulat o ry def ormity in th ese meta ca rpals is no t to lerated as w ell a nd must be cor rected. P.1 61 R ather than attempting a variety of maneuvers to correct the very co mmon angu lated fracture of the fif th met a ca rpal, it is rec o mme nded that th e h and be splin ted in a fu nc tion al posit ion for 10 days. Th is po sitio n inc lude s maxim u m flexion o f the MP j oin t and slight fle xion of th e in ter phala ngeal joints
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to ma intain the ext enso r ho od an d capsul e of these join ts un der m axim u m ten sio n. Th is is si mi lar to Bu rkhalter's technique described i n th e preceding section , but it may be accomplished by a simple l ateral gutter splin t (Fig. 5-14). Angula ti on up to 40 degrees m ay be accepted provided no excessive rotation exists.
FIGURE 5 -14 Fo r frac tur es o f the 4th and 5th metacarpal s, a si mpl e la te ra l splin t may be appli ed. This sp lint immo bilizes both the fractur ed and the adja cent u ninj ured finge r. The M P joint is flexed 7 0 to 90 degrees and the IP j oints are flexed slightly. Th e fingertips are di re cted tow ard t he scapho id tu berosity to in sure ro tat ion al alignme nt. ( Modif ied from Co nno lly J. Fra ctu res an d dislocation s. Closed ma nagemen t. Philadelph ia: W B Sa unders, 1 995, with permission .)
W ith this a ppro ach, patien ts are usuall y fully re co ver ed by the en d of 4 weeks a nd a ble to retu rn to full vo ca tiona l a nd a vocatio na l activities. On re tu rning to work a few patien ts may te mporarily lack full exten sio n of the P IP o r MP joint, bu t these deficits usually dis appea r qui ckly. P reviously described methods of closed reduction of fifth metacarpa l fractures recommended ma nipu lation followed by ma intena nce of the han d in a variety of a wkward position s. These a pproa ch es tend to be asso ciated wit h comp licatio ns tha t are no t seen with t he Hunter-Co wen a pproa ch . O ne sh ou ld be careful to dis ting uish th e me ta ca rpal sh aft fra ctu re fro m a frac tur e i nvolv ing th e p ro ximal c arpal-metac arpa l joint. Displa ced articula r fractu res in this area ca n cause prolo nged d isability a nd are be st tre ated by ope n redu cti on an d intern al fixatio n.
LOWER EXTREMITY FRACTURES COMMONLY TREATED NONOPERATIVELY WITHOUT MANIPULATIVE REDUCTION Fractures of the Forefoot
Th e ma jority of frac tur es o f the fore foot includin g pha lange al and metat ars al fractur es can be tr ea te d b y closed nonoperative methods consisting primarily of a compression dressing with a subsequent sh ort leg walking ca st or brace (8 8, 8 9). E xce pti ons to th is gen eral ru le include m ultiple fra ctu re s or fracture dislocations, a nd selected fra ctu res in zon e III of the fifth metatarsal (90) (Fig. 5-15). Fractures in zone II or I are sta ble a nd ca n u sually be tre ated symptoma tically. Th e treatment i nitially is wi th a sho rt leg walkin g cast, a lthou gh many patients , pa rti cu larly with zo ne I f ractu res , a re mo re co mfo rtable w ith a n e lastic wrap an d a fu nc tion al me tatarsal b race . T his brace h as bee n d evelope d by Raibe l an d Colditz and c onsists o f a 1/8-inc h thick moldabl e pla stic material applied d ire ctly ove r the metatar sals (90). The brace has an open ing on the m edial side and a cu rved sha pe molded arou nd th e fifth metata rsa l to prevent move ment of the metatarsals while withstan ding th e fo rce of a mb ulatio n. Dame ro n (90) has found t his bra ce ef fective in tre ating ac ute fractur es after a sh ort pe rio d of imm o bilizatio n a nd elevatio n to redu ce ede ma. It can be used in any patien t with a zone I or II fra ctu re . Zon e III fra ctu res tend to be stress fractures in young individuals invol ved in a thletic s. W hen discovered early, P.1 62
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fifth meta ta rsa l stress fra ctu res can be tre ated nonoperatively by modification o f activity a nd use of th e functio nal metatar sal brace. H oweve r, when the fra ctu re beco mes co mpl ete, active athle tic i ndividua ls pref er operative fixation t o allo w e arlier resu mpti on of th eir lifest yle.
FIGURE 5 -15 A. Damer on an d oth ers ha ve po inted out tha t there are th ree a nato mic zo nes a t the base of the fifth metatarsal that are i mportant for treatment of the fractures of this bone. The first zo ne inclu des t he art icula r surface of the fifth meta ta rsa l-cu boid jo int. The secon d zo ne encompa sses the art iculatio n o f the proxima l fou rth an d fifth metat ars als. The th ird zo ne exten ds 1.5 cm di stal to t he second z one. B . A f unctio nal brace may be appl ied f or fractur es of the proxim a l f ift h met atarsal (zon es I a nd II). This ca n a void the need of a cas t o r o per ative fixat ion f or the usual fra ctu re in this locat io n. (Mo dified fro m Damero n T. Fractur es of the proxi mal fifth metata rsa l: Selecting the best treatment option. J Am Acad Orth op Surg 19 95 ;3 : 110 1 14 , with perm is sion.)
W ith most meta ta rsa l fractures, the type of treatmen t doe s not seem to have any direct e ffect on the l ength of time until symptoms subsid e. As with o ther fractures, such as ulnar or scaphoid fractures, ra diograph ic evid ence o f hea ling is slo wer tha n is clinic a l un ion . In a ge neral ortho paedic practice Dame ro n fo und more than 9 0% of th e fifth m etatar sal fra ctu re s occur in zon e I and ca n be tr eated sympto mat ically and function ally; 7 % to 1 0% occur in zone s II and III a nd th ese ma y be gene ra lly slo wer to h eal than the more commo n zone I frac tur es (88 ).
Calcaneal Fractures
Th e u su al mechan ism produ ci ng a calca neal fra ctu re is a fall on to th e h eel from a heigh t, resulting in b oth extraarticula r an d intraarti cu lar fractures. Most extraarticular fractures can be treated symptomatically. If the patie nt is minimally symptomatic, th e foot is first ma naged by th e R IC E tec h nique , fo llo wed by early mobi lization . Cast immobi lization ma y be consider e d, but general ly it is b est to keep immobilization to a minimum because stiffness of the foot from prolonged immobilization d uring trea tm ent ca n be a sou rce of lo ng- term fun ctio nal impair men t. Ma ny intr aarticula r calcan eal fract ures can also be trea ted n onop erat ively usin g earl y mo bilization
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me th ods. A multicen ter study done by th e C ana dian ortho paed ic tr auma study gro up (91, 92) showe d th at mo st patien ts wit h a displ aced in tra art icular calcane al fractur e tre ated non operativel y will no t n eed su rgery a t all. Approximatel y 2 0% will have a less than satisfactory outco me a nd require a su bta lar arthrodesis. Th is study demon strated that there is a select pa tie nt group with displa ced i ntr aart icula r calc an eal fractur es th at do p oorly relative to oth er patie nts . This gro up includes you ng ma les, workman compen sa tion board pati ents, heavy la borers, or those patients wi th a fra ctu re p atte rn wi th a Bo h ler a ngle of les s th an 0% an d a San der s-type IV fractur e. These patients wit h frac tur es th at in volve the intraa rticu lar surf ace of the calcan eus a re prime candid a tes f or i nitial open re duc ti on an d inter n al fixa tio n t o decrease th e possi bility of the futu re ne ed for su btalar fusio n. If the patien t is to be treated nonope ra tively, in ma ny i nsta nces no attempt at reduction is n ecessary. Ho wever any c linical def ormity, pa rtic ul arly h eel valgus or any later al or plan ta r bony p rominen ces require correction . E ven if reductio n o f the fracture is n ecessa ry, mob ilization is helpf ul to dim inish edema an d preven t stiffness of th e joints . A calcan eal fractur e, whic h invo lves a la rge amo un t of ca ncello us bo ne, usual ly a chieves sta bility immedi ately du e to impac tion of the fragments at the time of the inj ury. Therefo re , to a ch ieve fracture imm obi lization o ne need only e liminate weigh tbe aring stresses (9 3). La nce and co -workers (94) f ou nd th at, in selec ting candi dates for early mo biliza tio n witho ut frac tur e re ducti on, there sh ould be a nea r normal clin ical appeara nce of the heel without perone al ten don i mpingem en t, and the x- ra ys sho uld sh ow m ain te nan ce o f re ason able co ngrui ty bet ween the po ster io r a rt icular facet of the talu s an d the calcan eus. Age and gene ra l h ealth s tat us a lso infl uence the sel ectio n. Patien ts who a re older th an 60 yea rs or who ar e chron ically ill ge nerally tend to do bes t w ith e arly a ctive mo bilizatio n. Th e tec hn ique of nonre duct ion with early mobili zation c onsists of simply elevatin g the inj ured foot for 2 t o 3 da ys in a co mp ression dressing and applyin g col d packs. By the third da y the patie nt sho uld b egin to e xerci se t he t oes, ta rsal j oin ts, and ankle syst ematic ally on an h ourly basis within the limit s o f pain . Af te r 3 or 4 d ays, the patien t may be up on crut ch es, bu t sho uld be cau ti oned aga inst w eightbearing or dependency of the foot. At the end of the first week, the foot is reexamined for any clinical deform ity or area of bon y protrusion on the lateral o r plan tar surface. X-rays are ta ken to d ete rmi ne th at th e fracture h as ma intain ed a n a cceptable position . If heel widen ing or de formi ty is e vident, closed redu ction by th e Omoto (95) technique , described be low in the section on ma nipu lative re duc tion of f rac tur es, or open reduc tion s ho uld be co nsidered (see F ig. 5 -49) . W eigh tbe aring is deferred for 6 to 8 w eeks with linear fractures and for 10 to 1 2 weeks for fractures w ith co mm inutio n. If displa ceme nt beco mes evid ent du ring trea tme nt, it is po ssible still to r edu ce the ca lcanea l fr actur e by ope rat ive me th ods. P ozo et al (93) a nd others have foun d tha t maximu m re covery a fter ca lcanea l fractures ma y require 2 to 3 years and that soft tissu e injuries are a sign ificant cau se for re sidu al symp toms.
Fractures of the Lateral Malleolus

Th e sequ ence of inj ury to th e supin ated externally rota ted an kle, a s descr ibed by Lau ge-Ha nsen, b egins u sually with a te ar of t he anterio r tibio fibu lar li gament followe d by a fracture at va rying levels of the lateral malle olus or fibu la (9 6). Often the anterior tibiofibul ar liga ment stretches but remains i ntac t. The fra ctu re o f the lateral malleo lus th en occurs a t the level of the an kle join t (Fig. 5-16 ). Th is type of fra ctu re is quite sta ble provided th e torsi onal injury did not advance further to involve th e po ste rior tibi ofibular ligamen t or the m edial malleo lus. For the m ost pa rt the undi spla ced or mi nimally dis placed later al malleo lus fracture is qu ite a nalogou s to an an kle sprain bu t often hea ls mo re ra pidly th an does a se ver ely sprain ed a nkle. It c an be trea te d with eithe r a short leg wa lking ca st or an air splint. It should be protecte d for a pe riod of 1 to 2 weeks with pa rti al w eightbearing fo llowed by full weigh tbearing in the cast or air spli nt. Walking without external support is usu ally p ossible i n 3 to 6 wee ks. It is importa nt to distingu ish the common fracture of the late ral ma lleolus at the ankle joint (9 7) f rom tho se fra ctu res o f th e f ibula a bove the syn desmosis, wh ich a re u nstable due to sh ortenin g a nd e xternal rotatio n. Ya blon et a l (9 8) an d o thers (99 ,10 0,10 1,10 2,1 03,1 04) have demo nstra ted the i mp ortance of a deq ua te closed or ope n redu ctio n t o resto re bo th length and rota tio na l al ignm ent of this type of fractured fibula. Failure to restore the fibula's P.1 63 l ength and rotatio n can resu lt in abn ormal lo ading of th e tal us an d po sttr a umatic a rth riti s (105) (Fig. 5-17).
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FIGURE 5 -16 A. Th e co mm onest type o f an kle fr acture invo lves the lateral m all eolu s at or slightly above the mortise. This is a spiral oblique fracture that may or may not be associated wit h a tear o f the anterio r tibio fibu lar ligament (stage I a nd st age II). If the supin ation extern al rota ti on injury rotates circumferentially around the mortise, the posterior ma lleolus or posterior tibio fibu lar liga ment will be in jured (stage III) . In stage IV th e del to id ligament or medial mall eolu s will be i njure d an d the fra ctu re m ay bec o me un sta ble. B . This sta ble fracture withou t sho rte ning or malrota ti on of th e fibula can be tre ated mu ch li ke a sprain wit ho ut re duc tion. An air brace su pport is helpful for early functional recovery. C. If the later al m alleo lus is sho rte ned or malrotated, a mo re un sta ble a nkle is the result and it generally requires operative treatment. In evalua ting th e co mm on fra ctu re of the lateral malleo lus one sho uld ca refu lly ex amine for dis rupt io n o f the tibiofibula r as well as the delt o id lig aments. (Modi fied fro m C onnolly J. Fra ctu res an d dislocation s. Closed ma nagemen t. Philadelph ia: W B Sa unders, 1 995, with permission .)
Fibula Shaft Fractures and the Maisonneuve Fracture

An is o lated frac ture of the fibula, wit ho ut a tibia l f rac ture, can o ccu r f rom a dir ec t i mpac t, s uc h as a k ick. These fractur es are co mm inuted an d con tra st with t he usual fibular fractur e occurr in g from a n i ndirect mecha nism, which tends to be oblique or spiral. The comminu te d, isol ated fracture of the fibul a can be tr eated sympto matically. This ma y requi re a sho rt leg-walkin g cas t fo r 4 weeks, a fter w hich full wei ghtbearing is u sually poss ible. This fracture should not be confused with the isolated fibula fracture in the upper third of the bone, w hich is produ ced by a torsion al inju ry to the ankle , the so-c alled Maison neu ve fr actur e. Panko vic h (1 06) and othe rs hav e pointed out the co mm on mecha nism of this inju ry in whic h t orsio n of t he an kle w ith th e foot slightly pronated or supi nated is transmitted along th e inte ros seou s ligame nt to the p ro ximal fibu la. In m o st inst ances the inju ry also pro duces disruptio n of the an te ri or tibio fibular l igament and/o r fractu re of the medial malleo lus, tea r of th e de ltoid ligam en t, or an an te ro medial j oin t capsula r tear. Th is in jury ca n lead to a wi de dia sta sis of th is distal tib iofibular articulat io n with
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d iffic ulty in redu ctio n and inter na l fixatio n. Alth ough P anko vic h (1 04 , 106) po inted out that most Ma isonn euve fra ctu re s of th e pro xim al fibu la wit h o r wi th ou t dias tas is o f the ankl e can be tr eated by ca st immobili zation f or 3 to 5 wee ks, the more advan ced stages of this lesion require repair of th e a nkle ligam e nts. Yablo n e t al ( 98) as wel l as Webe r an d Simpson ( 10 5) h ave show n th at restora tio n of len gth a nd rotation o f the fibular fracture i s sometimes key to co rre cting diastasis P.1 64 of the distal ankle joint a nd correctly restoring the ankle mo rtise .
FIGURE 5 -17 This a nteropo sterior x- ray o f both ankl es sho ws a proxima l fibula frac tu re tha t ha s hea led with sh ortenin g a nd ma lrotatio n, res u lti ng i n ma lalign me nt o f the ankle mo rtis e and a loss of the normal ta locrural angle compared to the opposite side. This usua lly resul ts in pers istent sympto ms, which can be allevia ted by correct ive rea lignmen t of th e fibula a nd ankle mortise.
Stress Fractures and Other Undisplaced Tibial Fractures

U ndis pla ce d tibial fra ctu re s require no redu ctio n and can gene ra lly be man aged with a fun ctio nal b ra ce o r a weigh tbe aring cast. I t should be remembered that fractures in the dista l tibia associated w ith an intact f ibula can develo p a va rus -internal rotatio n defo rm ity in the cast. T his may be co mbated by extern ally ro tat ing the dis ta l fragment wit h the ankle at th e time of ca st applicatio n. Th is shifts the floor reaction force lateral to th e fracture th ereby di minishing the tendency to varus a ngul ation . Ma nageme nt of tibial stress fractures has been problemati c because they most often occu r in active y oun g in dividual s such as mili ta ry recruits a nd athletes (107, 10 8). T he earli est symptoms a re pai n a nd sw elling loca lized typical ly to the mid dle of the tibia, within 6 to 12 wee ks after begin ning v igoro us run ning or forc ed mar chi ng. The patie nt presen ts wit h a sligh t limp and has tender ne ss to p alpation. Th is con dition has been called a stre ss reaction o r stre ss process rath er then a complete frac tur e at th is poi nt bec au se it begins wit h an area of h yperemia of the bo ne before th e x-r ay sh ows a fracture line (109). The diagnosis is made at this stage by either a radionuclide bone scan or more l ikely by magn etic reson ance imagin g (M RI) of th e bone. Th e prima ry treatment is to avoid continu ed repe titive lo ading of the bone stre ssed by ru nning or ma rching. Th is usu ally re quires mo difi ed a ctivity and res t with t he avo idance of ru nnin g. C on dition ing ca n be main taine d by exercises such as swimming, bicycling, or stretching, but re petiti ve loadin g activity sh ou ld be avoided for 6 to 10 weeks. Th e a th lete w ith symptoms of stress fracture (some times called sh in splin ts ) of the lower leg i nvol ving th e tibia o r the fibu la c an be trea te d by a sem irigid pneu matic le g brace (1 07). This a llows th e individual to con tinue playing the sport until the sy mptom subside s. Howe ver, for a co mplete fracture throu gh th e tibia , more supportive treatment is u su ally necessary, su ch a s a fracture brace
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or c a st.
Intertrochanteric and Femoral Neck Fractures

Alth ough a dis placed intert roch anteric fracture in an elderly patient is mo st efficiently fixe d inte rn ally (1 10), an undispla ce d in te rtr o ch anteric fractur es in th e youn g adu lt n eed n ot necessarily re quir e i nternal fixation . The strong c ortical bone o f th e i ntertroc han teric region i n th e younge r patien t often mi nimizes co mm inutio n of the fra ctu re a nd th ereby preve nts sho rten ing or varus angul ation . This allow s for treatment by a brief period of bed rest (1 to 2 days), symptomatic pain relief, and partial w eightbearing on cru tch es (Fig. 5-18). Most patients can return to work in 2 to 3 weeks. Operative fixat io n, in co ntr ast, may actua lly slo w do wn the retur n to full weigh tbearing and to work for the y ounger patie nt. No no perat ive tre atm ent of femoral neck fractur es in s enile patien ts has also been advo cated (111 , 1 12 ) as a reasona ble a lternative to the frequently co mplicated operative treatment. Nonoperative treatme nt ma y be most h uman e for the elderly be dridden patient who ha s been n onambulatory prior to the h ip fra ctu re. E mphasis should be placed on avoiding pressu re sore s using special mattresse s, h eel protec tors, a nd freque nt turn ing. F or such patients w ho are unli kely to wa lk a gain, no nope ra tive ma nage ment is a re ason able alterna tive , whi ch a voids th e men tal a ngui sh , expen se, an d h ospitali zation o f su rger y, prov ided go od nu rsin g care is a vailable (11 3). A key fac tor in deciding a bou t operative v ersu s nonoperative treatment for the elderly bedridden patient shou ld be the clinical e xamina ti on of h ow pain ful the affected hip is wh en internal ly or externa lly ro tat ed. I f the patien t see ms to be i n co nsiderable pain, which is m ore often th e ca se with extracapsular inte rtroch anteric fractures as compa red with intra ca psular femoral neck fractures, operative tre atment sh ou ld be seriously considered. St ress frac tur es o f the femo ral neck ma y also occur in a ctive yo ung individu als. The y may o r may no t re quire i nter nal fi xation ( 11 4,11 5,1 16). Th e u su al re co mm enda tion is f or inter na l fixatio n of fatigue or stress fractures tha t involve the su perolateral a spect of th e femora l neck. T hese fractures are su bjected to ten sil e loads, a nd th eoretical ly may dis place, leadin g to a varus defo rm ity an d n onunio n. In contra st, incompl ete fractures that involve the infe romedia l aspect of the fe moral neck are su bjec ted to c o mp re ssive lo ading and can b e tre ated by no n-weightbea ring wit h crut che s an d caref ul fo llow-up. Howe ver, if there is a ny question ab out the stabi lity of th e fracture or th e a bility of the p atient to u se crutches properly, th e preferable P.1 65 P.1 66 a pproach is to f ix th e u ndisplaced femo ral neck stress f racture with mu ltiple pins.
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FIGURE 5 -18 A,B . Ant eropo sterior (AP ) and latera l x-rays sh owin g an u ndis plac ed intertroch anteric fracture in a 30 -year-old laborer who fell 1 2 fee t on to his h ip wh ile at work. He was trea ted symptoma ti ca lly w ith bed res t f or 2 d ays an d the n w as u p o n crutche s an d o ut o f th e h ospital. C,D. A P a nd later al x-ra ys show healin g evide nt at 4 weeks when the patien t was able to r eturn to work on a fu ll- time bas is. It i s questio nable whe th er thi s wo uld have been likel y if he ha d bee n trea te d with o pen re duct ion an d in te rn al fixatio n of th is completel y un dis plac ed fractur e.
In a prospective study of 170 cases of impacted femoral neck fractures, Raaymakers and Marti (117) fo und that functio na l treatmen t was just if ied in bo th yo un g an d o ld pa tients. This approa ch co nsisted o f a per iod o f a few days of bed re st in a splin t un til the acu te pai n from the fractur e subs ided. By th e end of the first we ek the majority of patien ts cou ld be allowed to bear weight pa rti ally with th e h elp of crut ches. P art ial weigh tbe aring was co ntinu ed for an aver a ge o f 8 weeks w ith event ual un ion i n 8 6% of th e pa ti ents. T he on ly pa tients wh o dem on str a ted instabil ity o f the impa cte d f racture we re th ose over 70 years of a ge a nd youn ger patie nts with seriou s illn esse s. Fu nctional, n onoperative treatme nt in most patien ts with impacted femoral neck f ra ctu res seems to be justified based on these a nd other report s (1 14,1 15,1 18 ,119 ,120 ,12 1,12 2) ( F ig. 5-1 9).
Pelvic Fractures
Approximately hal f of pelvic fractures result from severe trau ma su ch a s motor veh icle a ccidents or falls from a height (123, 124). The other half are caused by moderate trauma such as a fall from a stan ding height. Most consistently, th e less se vere mechanism occurs in the older age group a nd re su lts in fra ctures of one or both rami (1 25 ). Many of th ese can be tre ated symptomatically without
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h ospitali zation (12 6). C onsequ ently, i n th e st udy by M elto n et al (12 7), wh ich in cluded all of the p elvic fractures occu rring in Olmsted County, Mi nnesota, over a 10-year period, 80% were con si dered mi nor. In a separate series of cases from the Mayo Clinic by Mucha and Farnell (128), 36% were classified as complicated or severe injures. Th is reflects the difference from the commun ity wide study of Melton's co mpared with a selective study from the perspective of a tra uma ce nter. Melton et al's stu dy was b ased in the Midwest co mm unity of R oches ter, Mi nneso ta , with a un ique re co rd ke eping and retr ieval system, a nd reflects the full spectru m of pelvic fractures seen in one commun ity . It portrays the p elvic frac tur e de mograph ics s een by mo st prac ticing ortho paedic su rgeon s. Overall, a mino ri ty of p elvic fractures (10 % to 20%) are th e result of significan t injury, su ch as auto versus pedestrian, that is likely to threaten life or the functional recovery of the patient. When these injuries do p re sen t, ho wever, th e po tent ia l for co mplicatio ns is high an d sho uld be reco gnized early to ensure p ro mp t a nd a ppropriate mana gem ent (129 ,130 ,131 ,13 2). Tempo ra ry resuscitatio n aids such as circumf erentia l wrap ping o f the unstabl e pelvi s with s heeting as des cribe d by Rou tt et a l (13 3) i s an e ffec ti ve met h od of st abilizin g the un sta ble pe lvic r ing an d the hemo dyna mi ca lly u nstable patient.
FIGURE 5 -19 An impacted femoral neck fracture was treated with a brief p eriod of bed rest follo wed by pr o te cted amb ul ation with crut ches a nd heale d with out furth er displac eme nt of the f ra ctu re.
A nu mber of excellent investigators ha ve classified pe lvic fractu re patte rn s in order to assess how u nstable the inju ry mig ht be. Th ese class if icat ion s are dis cu sse d elsewh ere i n th e text and are p articu larly pertinent to operative man agement. How ever, it sh ou ld be kept in min d that the main morbidity a nd mortality from pelvic fractures come from associate d head, cardiovascula r, and a bdomin al injuries rathe r than f rom th e pe lvic f ractu re itself. C linica l assess ment of pelvi c fra ctu re ins tabi lity is espe ci ally im portant if one i s conside ri ng n on operative treatment. Non operative treatment of unstable inju ries using external fixators has been re ported to be ine ffective (13 4). More o ften, c losed tre atment of a displaced fracture requires temporary ske letal tra ction to correct shortening and torsion al deformity of the pelvis. For th e mos t co mmon pelvic fracture without sh ortening or torsional deformity, involv ing either the anterior or p osterior ring, n on operative symptomatic tre atment ca n be quite effective (135 ).
Anterior Pelvic Ring Injuries

O pen tre atment of symphys is pu bis separa ti on ha s been advo cated b ut rarely is n ecessa ry, even with w ide sepa ration , whi ch c an be closed by extern al fixatio n (1 36 ) an d do es not ordinarily caus e lon gterm problems. Indeed, symph ysis pubis se paration ma y often spon ta neously close a s the patien t is a llow ed to bea r weigh t and correct th e rotation al alignme nt of the limb (Fig. 5-20). Also, pregnan cy
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fo llowin g trau matic pubi c symphysis sepa ra tion is mo re l ikely to be a problem if the origin al inju ry w as tr eated surgically than if it was a llow ed to he al wit hou t reduc tio n (137) . Se paration o f the pubic symph ysi s in as sociat io n with pre gnan cy, labo r, an d deli ver y is ra re bu t may b e asso ci ated wi th a cu te pai n, pa rticu larly w ith we ightbearin g o r flexion o f the hip. Lin dsey a nd co a utho rs ( 13 8) review ed this problem an d repo rte d tha t simply pla cing th e pa ti ent in a la te ra l d ecu bitus position , which permits spontan eou s reduction o f the diastasis, can relieve the symptoms. A well-padde d pelvic binder m ay be a pplied a nd th e pa tient can be treated sympto matically with bed re st until the pain subs ides. In genera l the separ a tio n of th e P.1 67 symph ysi s pubis is less th an 1 cm, and no no per ative trea tm ent a llow s comp lete fu nction al re co ver y.
FIGURE 5 -20 A. A nteropo ste ri or x -rays of a pelvic inju ry sho w initial separ atio n of t he symphysis pu bis and sacroiliac joint. The patien t was tre ated symptoma tically with parti al weigh tbearing on crut ches wit hin 1 week after inj ury. B . The separat ed symphysis pu bis was seen to be clo sed spo ntan eou sly o n th is x- ray 1 mo nth afte r the origin al inju ry.
O perative fixatio n of th e symphysis pubis o r a nterior pelvic rin g may be necessary oc casionally in co njunction with repair of ge nitou rinary injuries. Displaced pu bic ramu s fra ctu re s in wo me n p articu larly sh ould be caref ully evalua ted sin ce they may be asso ciated with va ginal lacera ti ons. Th ese can r equ ire o perative fixa ti on to avo id or treat co mplicatio ns in cluding vesicova ginal fi stu las or chronic infection (Fig. 5-21). O per ative ext ernal or interna l fixatio n of the anterio r pel vic r ing shou ld a lso be co nsidered when the frac tur e dem on str ates clinic al instabili ty, as e videnced by sho rt ening an d ro ta tiona l de formity of th e l imb o r palpa ble mo tion o f the iliac wing (F ig. 5 -2 1). In s uch ca ses stabiliza tio n of bo th th e ant erior a nd p elvic rin gs are genera lly indicated.
Posterior Pelvic Ring Injuries

Th e ma in residu al orthopaedic problem from pelvic fracture is pa in from a separated or fractured sa cro iliac joi nt (13 9, 140). Many patien ts c ompla in of sacroil iac j oint pain for 6 mo nths to a ye ar a fter the pelvic fracture, wh ether th e j oint ha d been treated ope ratively or n on operatively (139, 1 41 ). Sa croiliac sympto ms f rom pelvic in jury, due to e ither fr acture or ligament disruption, will gene ra lly h eal spon ta neo usly. Ho wever, heali ng of the ligam en tous inju ry can take a good de al lo nger than d oes h ealin g of the fractured sacrum or il ium (141). Neverth eless, ligaments do heal spontaneou sly w ith time (142). Conseque ntly, a cu te fixat io n o f every separ ated sacroilia c joint does not seem w arranted since in most cases th e symptoms subside or dimi nish (Fig. 5-22). This ha s been shown in a n umber of studies analyzing l ong-term residual problems from major pe lvic fra ctu res treated n on opera tive ly ( 13 5,13 9,1 43) . Henderson (13 5) , in revie wing re su lts f ro m th e U niversity o f I owa , fo und that ma ny patients with ma jor anterior or poste ri or pe lvic disruption d id have a t least some d egree of dis abilit y, but 6 2% ha d no disa bilit y. If the pelvic fracture was mea surably unstable i nitially, the ch ances of long-term disabi lity increa se d signif icantly. Most di sa bility wa s associa ted w ith th e a mo un t and severit y of vert ical displacemen t throu gh th e sa cro iliac joi nt. Alt hough back pain
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w as a fairly common compla int in patients followed up for pelvic fracture, it was not considered p articu larly se vere. The pelvic fracture patien ts were no more likely to have visited a doctor or be en h ospitali zed for low bac k sympto ms than we re no rm al co ntr o l patie nts in the Iowa popu latio n. Furt her su pport of the Iowa study comes from a n umber of case reports of patien ts with bilateral sacroiliac d islocatio ns ( 24 ,144 ,14 5,14 6,14 7). The se in dica ted tha t even the un ique bilateral inj uries ca n be trea te d nonoperatively with surprisingly goo d functio nal outcome de spi te comple te dis placeme nt of th e sacro iliac join ts. O th er in vestigators who ha ve be en a dvocates of o perative fixa tion of th e sa cro iliac join t ha ve d ete rmi ned th at a natom ic reduction of the sacroiliac joint is importa nt to correct pelvic obliquity and re store leg len gth (126, 140 ). But even with atomic reduction of th e sa croiliac joi nt many pa tients w ill still experien ce some degr ee of posterior pelvic symptoms (1 48, 14 9).
SPINAL INJURIES Cervical Spine Fractures

It has be en sa id th at the ease with which a c ervical spin e fracture ca n be sus tain ed is exceeded only b y the ease with which the diagno sis may be missed . Any p atient wit h nec k pa in af te r a direct blo w to th e head or neck should be ca refu lly eva lua te d for cervica l spine fra ctures . This i s part icula rly true fo r the elderly P.1 68 P.1 69 p atient wit h o steoa rth ri tis or ankylo sing spondyl itis who s ustai ns a mi nor h yperext ensio n i njury to t he neck (1 50) (Fig. 5 -2 3). Th e gen eral ossifica tio n of th e arth ritic or ankylo sed spin e ca uses it to fracture readily, like ch alk, w ith min imal inju ry (15 1).
FIGURE 5 -21 A. Alth ou gh mos t pubi c ramus fractures do not require ope ra tive fixation, th is dis plac ed fra ctu re pen etra ted the patien t's vagin a and re su lted in a vagi nal laceratio n and a subs equ ent ve sico vagin al fistula. Displa ced pu bic ram us fractur es in women sho uld be eva luated carefully fo r associa te d gyne co lo gic inj uries . B . Clin ical as ses smen t o f pelvic inst abi lity is ba sed on evidence of sh ortenin g a nd e xtern al ro tatio n of the limb ( 1, 2 ) as we ll a s
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a palpa ble sen sa tion o f motio n when an inter n al or exter n al ro tatio n force is app lied to the ilia c win g (3 ). The se findings genera lly co nfi rm the need for extern al or i nternal fi xation o f the pelvic injury. If closed tre atment i s dictated by o th er injuries, th e e xte rn al rotation and sho rtening of th e limb can be co rrecte d by dista l fem ora l traction u ntil e arly h ealin g occurs. (Modified from Connolly J. Fra ctur es and dis loca ti ons. Clo se d man agemen t. Phi ladelph ia: W B Saunders, 1995 , with permission .)
Slu cky a nd E ismont (152 ) ha ve rec o mme nded th at trea tme nt of acute inju ries o f the ce rvi ca l spina l co rd should stress patient resusci ta tion, spinal immo bilization , a nd skele ta l traction for fra cture re ducti on an d ali gnment. In t heir experien ce appr o ximately 40 % of t hese inju ries h ave been a ppropriatel y treated nonope ratively. Operative treatment does play a ro le in decompressing a nd st abi lizing th e cervic al s pine elect ively aft er the patien t is a cutely stabi lized (1 53,1 54 ,1 55 ,156 ,15 7,15 8,15 9).
Central Cord Injuries

Although most cervical spi ne fractures with spinal cord in jury require prompt stabilization , some co nditions are prime candidate s for nonoperative treatment without reduction. Th ese i nclude cervical spine in jurie s produ cing a central cord syndrome ( 160 , 1 61 ). Most often these patien ts present w ith i ncomplete p aral ysis and a puzzling lack of evi denc e of eithe r a fra ctur e o r disloca tio n. This can o ccu r i n a pproxim a te ly 15% of pa tie nts with signif icant neuro logi c inj ury. The class ic mech anism is a h yperextensio n of the c ervic al spi ne in a n older patient with arthritis, disk disease, or spo ndylitis (F ig. 5 -23) (16 2). T h is sudden hype rextension cau ses hem o rr hage into t he central po rtio n of the co rd, resultin g in upper extremity pa ralysis greate r than the para lysis of th e lower extre miti es. The co rticos pinal tract (motor tract) an d spinothal amic tract (pain a nd tempe ra ture) may be sp ared or j ust pa rtia lly in volve d. Th e cen tra l co rd lesio n ca n be con firmed by a n MR I sca n th at sh ows hemorrh age into the ce ntr al p ortion o f the cord. Man agement of th e pa ti ent wi th a central cord lesion , wh ich is an incompl ete n eural inj ury, does not re quire su rgica l treatment. In fact, operative treatment may occasion ally i nterfere P.1 70 w ith circula tion to the co rd a nd dim inish the ch ances of recov ery. Heav y traction o n th e neck sho uld a lso be avoide d since this ma y dis tr act the inj ured co rd a nd w orsen the neuro logic defi cit (1 63,164,1 65 ). The pri mary treatment is to protect the spi ne with a cervical orthos is to prevent re cu rre nt h yperextension and advise th e pa tie nt a nd family that chan ce s for so me recovery are u sually fairly go od. Ish ida and Tomina ga (166 ) have sho wn that i f a pa tient h as only invo lvemen t of th e u pper extremities with norma l strength in the legs prognosis for recove ry at abou t 6 week s is a lmost 100 %. Motor re covery occ urs before sensory recovery. This is particularly true fo r patien ts w ithou t abn ormal MRI sign al i ntensity in th e spina l co rd. Outco mes are not as favorable for pa tients w ith initially severe n euro logic damage an d older a ge.
FIGURE 5 -22 A. A 90 -year -old male ped estr ian sustaine d this fractur e of th e a nterior and
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posterior pelv ic rings when he was struck by an automobile. There is x-ray evidence of inst abi lity with widen ing of the sac roili ac joint and dis placed fractures of the pubic rami. Th e patien t's pelvis was stable o n clin ical testing. Conseque ntly, the fractu re was treated symptoma tica lly in this elderly gentleman wh o was permitted to walk with a walker and was discharged from the reh abilitative service 7 da ys after fra ctu re. B . T he patient was mi nimally symptoma tic and fully w eightbearin g at 3 month s. F ollow-up x -rays sh owe d tha t the posit io n o f the pelvic fract ures re mained un ch ange d. This illustrates tha t careful evalu ation o f th e clin ical stability of the pelvis is a key determinant in selec ting approp ria te ma nagemen t.
FIGURE 5 -23 A. The cla ssic mechan ism of i nju ry in the elderly p atient wit h long -standi ng cervic al art hritis or ankylosin g spo ndylitis is a hyper ext ensio n blow to the head. B. Th e exten sio n inj ury c an cau se he morrhagi ng in to the cen tral po rtion o f the co rd ( 1 ), resu lti ng in central cord sy ndrome. This generally damages the central portion of the gray ma tte r, resulting in upper extremity pa ralysis that may or m ay not be greater than lower extremity involvemen t. The corticospinal tract (mo tor tra ct) and th e spinotha lamic tract (pa in and temperature) ma y be spared or onl y partia lly involved ( 2). (Modif ied from Conn olly J . Fra ctu res an d dislo ca tion s. Cl osed manage ment. P hilade lphia: WB S aunde rs, 19 95, wit h per mission.)
Ankylosing Spondylitis
An other prime ca ndidate for nonoperative treatment of a cervical spine fracture is the patien t su ffering from an kylosing spondylitis (167,168,169). Th ese fractures frequently occur as a resul t of mi nimal t raum a an d are as socia te d with severe neuro logi c def icit in appro xim ately 75% o f ca ses. F rac tur es a re o ften u nsta ble, bu t no no per ative tre atm ent is alm o st un iform ly successful in ach ieving u nion (1 68 ). Alth ou gh th e mo rta lity ra te in patients treated n on operatively is high, the rate of mo rtality amon g patie nts undergoing surgical treatment is co nsiderably higher (50% or more). No no per ative mana gem ent also is n ot w ithou t complica tio ns si nce th ese patie nts tole ra te bo th be d re st and brace treatme nt poorly because of sign ifican t pu lmonary in su fficiency. The compromise trea tme nt includes a brief pe rio d of halo or skull tra ctio n followe d by im mobili za tion in a c ervic alth oracic bra ce (Fi g. 5-24) adjusted specifically to accommodate the kyphosis tha t usua lly re su lts from th e a nkylo si s (167). Mana gem ent within a s pec ialized spinal cord inju ry unit pro bably facilita te s and o ptimizes th is form o f mana gem ent. Th e i mpo rt ant poin t to keep in mind in tr ea ti ng any of thes e p atients is the ease wit h w hich th e spin e can be fra ctu re d after min or inju ry such as a blo w to t h e h ead, and the si gnif ica nt co mplication s tha t fo llo w operat ive as we ll as nonoperative trea tm ent of this l esion ( 16 2,16 8,16 9).
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Bracing of Cervical Spine Injuries

P atien ts wit h ce rvi ca l (C) spi ne fractur es wit hou t ne urolo gic def icit requ ire careful and critical co nsiderat io n of man agemen t o ptions (170 ). The stan dard option h as bee n w ith h alo brace i mmobiliza tio n, but th is tec hniq ue h as be en fo und to have a numbe r of drawbacks (1 71,1 72 ,1 73 ,174 ,17 5), es peciall y in eld erly patien ts (150 ,151 ,17 6). Eve n li ght tractio n in tentio nally o r in advertently applie d thr o ugh the halo ca n distr act th e frac tur e pro duc ing no nun ion , particula rly o f o do ntoid fra ctur e s (165, 177). Se ver al stu dies (17 8,17 9,18 0) h ave show n th at immo bilizatio n of the cervica l spine fra cture with a rigid Philadelphia co llar or a c ervic al-thoracic brac e can be a s effective a s a ha lo fo r man y cervic al fra ctu re s. Polin and co-wo rke rs (178) ha ve sho wn that odo ntoi d fractu res ma y be treated with a rigid Ph iladelph ia co llar or a cervic a l-th oracic bra ce ( Fig. 5-24). The type II I fractures at the base of the odontoid heal consistently with this me th od. Th e ma jority of th e more u nstable type II f rac tur e i n th e middle o f the odon toid may also hea l satisfacto rily. P art icularly in the e lderly, it is no t a lways n ecessary to ac h ieve bony un ion for frac tur es o f the odo nto id (17 6). S table fibrous un ion can be an acceptable o utcom e, provided there is no myel opath y and the elderly patien t i s a poor can didate for the surgical fusio n (181 ).
Thoracic and Thoracolumbar Fractures

O ne of the proble ms in evalu ating mana gem ent approa ches to spine fra ctu res is th at we o btain most of o ur reports toda y from spine cente rs to which inj ured pa tients a re referred specifically because of co mplex problems. Th is has produ ce d wh at might be considered a distort ed pe rspective and i ncon sistent data. Saboe a nd co -w orkers (182) for example , in reporting experie nce from a single tertia ry care spi nal uni t, indicated that approxi mately 3 8% o f spine trauma patients w ere referred to th eir cen te r with neu ro lo gic invo lvemen t. I n co ntr ast a large dem o graphic stu dy by Riggins and Krau s (1 83) found the overa ll frequen cy of nerve inju ry wit h spine fractur es was 14% . In ge neral the frequency of neurologic deficit can be expected to range from 40% for patients with cervical spine fractures to be 10% with th oracic spine fractures, 4 % with th oracolumbar spi ne fracturesd islo catio ns , an d 3 % w ith lu mbar spin e f rac tures (18 3, 184 ). O th er populati on studies i ndicate th at th oracic and th oracolumbar compression fractures without a h istory of inj ury a re qu ite frequen t an d can be seen in abou t 1% o f patients under the age of 3 0 but i n mo re th an 3% of pa tients o lder th an 80 yea rs of a ge. The freq uenc y of a sym pto matic frac tures o f th e thoracic vertebrae in elderl y osteoporotic patie nts can exceed 20% (185,1 86,187). In the elderly osteoporotic patient, as soon as th e pain symp toms from th e th oracic fracture su bside, th e pa ti ent ca n be star ted o n a program of exten si on exerc ises to regai n pa ras pinal mus cle function a nd prevent kyphotic defo rm ity. These include str engt hen ing the upper th oracic paraspina l mus cles b y do ing wall pus h-ups . Lu mb osacral and pelvic mus cles can also be str engt hen ed to a void lon g-ter m sympto ms. Suc h an appro ach is most re adily accept ed by the elderly patients su bjec t to the proble m. P rolonged bedrest or an y type of spinal su pports tend to worsen symptoms and should be avoided. Th ese pa tie nts do no t to lerate braces or corsets ve ry well (188 ). Any evidence of neuro logic i nvol vement warrants a n evaluation for tu mor, e ith er metasta tic or primary, a s the unde rlying ca use of the fra ctu re s. Some patients w ith o ste oporotic vertebral fractu res may occasional ly expe rience pe rsistent pain an d fun ctio na l impai rme nt despit e several mon th s o f th e u sual no nope ra tive trea tme nt. A tech nique o f b alloo n kypho plas ty h as bee n fo und effective a nd sa fe in relievin g pai n, restorin g vertebral bo dy h eight, and patien t qual ity of life (189 ). Kyph oplast y is a minima lly invasive su rgical proc edure which i s guided by x-ray image s. It consists P.1 71 P.1 72 of an inflatable bone tamp being directe d into th e fractured ve rtebral body to restore the body h eight. Fixa tio n is the n do ne by fillin g the vo id with viscou s cem ent under vol ume co ntrol. The method has been effective in relieving symptoms both from osteoporotic fractures and pathologic fractures of the thora columba r spine. How ever, the optimal time interval for i ntervening with this me th od sti ll n eeds to be determined (189 , 1 90). Inj ecting ceme nt too soon after an acute verte bral b ody fractur e can lead to ce ment le akage an d ser io us n eurologic c o mp lication s (19 1). C onsequ ently, i t is reco mmended to wait a t lea st several mon th s wh ile th e vertebral bo dy ha s go ne th rough a pha se o f he aling to achieve t he m axim u m effect from the per cutane ous ver tebropla sty or kypho plas ty
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FIGURE 5 -24 Cervical bracing. Because of th e pro blems f requen tl y associa ted with the use of a halo, recent studie s indicate that a sta ble u pper cervical spine can be treate d with a Ph iladel phia colla r (A) , or a four-poster bra ce ( B), o r a ste rn al occipit al mandibu lar imm o bilizatio n (S OMI ) type of brace (C). Stabil ization o f odo ntoi d fractures as well as lower cervical spine fractures may be po ssible usin g a c ombin ed P hila delphia col lar with a mol ded fiberglass exten sion that fits on the chest (D,E). Pa tie nts in an y o f these cervica l o rth oses sho uld be foll owed carefu lly by radio graphic and clinical eva luatio n to de te ct any d elay ed dis placem en t o f the f rac ture. (Mo difie d f rom C on nol ly J. F rac tur es a nd d islocatio ns. Cl osed man agemen t. Ph iladelph ia: W B Sau nders, 1 995, wi th perm issio n.)
In the you nger patient, ma nage ment of thora cic fra ctu res introduces more potential problems (1 82,1 92 ,1 93 ) than do es the simple wedge fractur e in osteo porotic bon e. Fredrickso n, Yuan, and cow orkers (26 , 194 ) have carefully reviewed indica tio ns for nono per ative tre atm ent i n yo un ger patien ts w ho sust ain m ore vio lent and unstable fra ctu res tha n a re seen in t he elder ly patien ts. Caref ul a sse ssmen t is requ ired pa rti cu larly in th e u pper thoracic spine to determine the s tability of the injury (1 95). In general, mo st of th e fractures of the thora cic spine down to T-10 obta in su pport from the rib cage. If there is any doubt about stability, a period of bed rest for 4 to 6 weeks followed by i mmobiliz a tio n in a b ra ce suppo rt is generall y indi ca ted in the patien t who i s neu rolo gic ally intact. If th ere is evidence of lateral displacement or loss of rib ca ge support, op erative fixation is warra nted. Th e advent o f compu te d tomo graph y (CT ) to eva luate spine fractur es has crea ted co ncern th at bo ne fragmen ts pus hed fro m the ver tebral bod y into the can al ma y cau se pro gressive ne urolo gic lo ss. This h as l ed to a nu mb er o f attem pts to defin e th e a moun t o f ca nal im pinge ment (5 0% to 60% o r more? )
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th at ma ndates operative interven tion ( 19 6, 1 97 ). On cri tica l analys es a nd follow- u p of patients i t a ppears that the primary determinant of neurologi c injury is the amou nt of direct dama ge su sta ined a t the time of the initia l fracture (1 98,1 99,2 00 ,2 01 ,202 ,20 3). O per ative fixa tio n on the bas is of arbitrar y interpretatio n of t he size of the canal fra gm ents h as n ot b een validated (204). In fact, l ong-term studie s indicate that fra ctu re f ra gments that bu rst from the v erte bral bo dy in to the ca nal remode l qui te con sisten tly an d the can al ca n de co mp ress spon taneo usly (1 94, 20 5). Th e use o f CT to deter min e treatmen t of spin e fractures see ms an alogo us to u sing only high -po wered mi croscopy to diagnose and treat bon e tumors. Both mo dalities ca n ma ke th e co ndition lo ok more ma ligna nt than it truly is (20 6). The fact that burst fra ctu res can best be treated s ymptomatically by re lieving pain, restoring paraspinal muscl e strength with exercise, a nd return ing the patient to as n ormal f unction a s possible was first demonstrated by Nicoll (207) in studies of British coa l mine rs. Su bsequently, oth er inv estigators of patients with work-related fractures of the spine ha ve rein forc ed Nicoll's observation (208,20 9,210). For many patien ts with compression fractures of the verte bra l b ody, th e residu al symptomatic impairme nt is related to th e du ra tion an d in te nsity of tre atment and n ot necessarily to th e a moun t of th e frac tur e co mm inu ti on. This is particularly tr ue in workmen's co mpensation patients treated for vertebral fractures w ithou t ne urologic injury (211). Th e la rge n umb er o f fra ctu re s of th e tho rac ic a nd lumbar spi ne see n i n min imally symptomat ic p atients su pports the gene ra l ru le that closed management is the treatment of ch oice (2 12 ,2 13 ,214 ). U nfortun ately, w ith the devel opmen t of mu ltiple i nter nal fi xation t echn iques and a ma ssiv e spina l i mplant industry, ma ny pa tients u ndergo open treatment of thora cic or thora columba r fractu res for q uest ion able indic atio ns (21 5,2 16,2 17 ). Th e use o f such te ch nology sh ould n ot e xce ed the gui delines su pported by common sense (2 18). A nu mber of ca refu l follow-up stu dies of inju ries treated by closed me th ods indicate that sta ble fractures do not re quire furthe r stabilization or even reduction (1 54,2 08 ,2 09 ,210 ). Such frac tur es include the commo n wedg e flexio n frac tur e as well a s vario us fractures i n th e tho racic spin e do wn to T-10 . The se un dis placed inju ri es are usua lly in tri nsic ally stabl e becaus e o f rib cage suppo rt an d may be treated adequatel y by a brie f period of bed r est to a llevia te pain symptoms follow ed by early mobili za tion an d exe rcis es (2 10). Spinal bracing may be p re scr ibed selectively dependin g o n the co ncer ns of the patien t. Ide ally, use of s uch bracing sh ould b e kept to a min imum (1 88, 21 9) sin ce it is gene ra lly bi omecha nically ineffective .
Fractures Below T-10

C losed treatment is gen erally indicated for most flexion -compre ssion fractures in th e th oracolumbar re gion belo w T- 10 with out nerve inj ury ( 21 4, 220). How ever, beca use the se fra ctu res no l onge r ha ve th e support of the ri b cage they can displace, pa rticularly i f th ey result from flexion-rotation inju ries. Inter n al fixa tio n then wo uld be indic ated (20 2,2 22,2 23 ). Most (70%) of th ese th oracolumbar inju ries with no or minimal neurologic deficit, su ch a s tempora ry i leus, bla dder we akness, or iso lated partial nerve root defic it, can be sa fely an d effectively treated by re latively simp le a nd time- pr o ven methods of clo sed man agemen t (20 8,20 9,21 4,22 3,2 24,2 25 ,2 26 ). C losed m anagement, however, should no t be equa te d to management by neglect (226). If bladde r or b owel weak ness (cauda equ ina syndrome ) is s uspec ted, ca re ful t esting for per ian al sensatio n and b ladder ca th eterizatio n a nd/or urodyn amic studie s are indic ated. Symptomatic re lief is o btaine d by a b rie f per iod of bed res t f ollo wed by exe rcises of the spina l suppo rt m us cles. T h e pa tie nt sho uld be fo llowed closely (202,21 8,22 7,22 8) for an y clini ca l o r radio graphi c chan ges to detec t u nan ticipa ted i nstability of the fractu re . For pa tients wh o present w ith mu lti ple n erve root paralysis, operative d ecom pression , including anterior decompression would be indicated (229 ).
MANIPULATIVE REDUCTION Mechanics of Reduction Based on Reversing the Original Mechanisms of Injury
Although a nu mber of fractu re s, as discussed in th e pre ceding section, can be treated by simply a llow ing mu scl e a nd j oin t P.1 73 fun ction to achieve alignment, ma ny re quire manipulative re duction to correct or prevent deformity. C losed reduction me th ods re ly on two basic techn iques. First, skeletal and soft tissue traction are re quired to restore length . Rotational manipulation then is necessary to correctly realign joint axe s of motion . Understanding mechanisms and potential probl ems is a s importa nt for cl osed non operati ve re ducti on as it is f or opera tive techn iques (34,23 0,2 31,2 32 ).
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Reduction of Fractures by Traction or Ligamentotaxis

Fractures re su lt from di re ct or indirect mechanisms. The majority of f ra ctu res produc ed by high-speed i nju ries common today result from a direct impact a gainst th e bone an d soft tissues. Th ese fractures a re cha rac terized by commin ution o f the fragm en ts, shorten ing, a nd angul ation determin ed by the d ire ctio n of the impac t. T o redu ce these an d man y o ther su ch co mmi nuted and sho rten ed f rac tur es re quires traction using th e principle of ligamentotaxis. Li ga mento ta xis is th e term used to e mphasize th at, to be effective, traction must be balance d by coun tertra ction provided by th e liga ments and so ft tissue s urr ou nding the bon e. This pull and cou nterpull resto res le ngth and guides alignme nt of the frac tur e fragm e nts. Thus, tra ctio n r elies h eavily on the soft tis sues th at a re u su ally att ached to at l east some o f the fracture fragme nts unless there is extreme stri pping (2 33) as in a grade III open fracture or an unstable disrupted fracture-disloca tion of th e spine. In these circumstance s traction sh oul d be applied caref ully to avoid c omplica tio ns ass ociated with overdis tracting t he inju ry ( 1 65,1 99 ,2 34 ). In t he pas t, trac tion wa s usu ally applied dir ectl y to the soft tis sues a nd skin , as wit h B uck's traction on the lower leg. A preferable method now in most instances is with some type of skeletal traction. Ske letal tra ction restores limb length and a ligns the fracture fragments close to n ormal whe n i t is counterba lanced by th e soft tissues s ti ll attach ed to the fra gments. Traction can be accomplish ed a lso w ith e xte rn al fixa to rs t ha t span the fractur e site or eve n spa n j oin ts. Supplemen ta l fractur e fragm en t fixat io n by perc uta neo us pin s or scre ws can also be used to p ro tect aga inst frac tur e redi spla cement a s the ligame nts stretch o ut over time. Such techniques are particularl y used for co mminuted frac tur es a bou t the knee, the ankle , and the wrist joint (235,236 ,23 7). Ligam e ntotaxis has also been u tilized to redu ce fractur es in the cervic al, th oracic, and lumbar spine by mea ns of hal o or other sk ull tra ctio n te ch nique s.
Initial Steps in Acute Reduction of Fractures

Direct a pplication o f tracti on is a mong the first e ssential steps to re duce a deformed fra ctu re d limb. Tempo rar y spli nting co mb ined wit h t rac tion can be effected by a variety of splintin g techn iques. O ne h istoric meth od has been wit h a Th omas splint, wh ich w as deve loped by H. Owen Tho mas in E nglan d a nd introdu ce d durin g World Wa r I by Sir Ro bert Jon es. This si mple techn ique of splinting resu lted in l owerin g the m ortality rate of gu nshot wound femur fra ctu res from w ell over 50% to approximately 2 0% un der those w artime circ ums tances. Su bsequen tl y, a wide variety o f o th er splin ts have been d eveloped to apply traction in order to stabilize the injured limb. A Hare splint is commonly used by re scue squa d person nel since it can s plint a de forme d femur a nd/ or tibia and mainta in stabi lity by d ire ct tra cti on (Fig. 5-25). Th e pa tient th en ca n be transported in rea sona ble co mfort to the e mergency facility. It is axiomatic th at in the emergency center fracture stability mu st be co ntinu ou sly main tained durin g acute assessment a nd mana gem ent o f the inj ured pa tient. U nfortunately, th is axiom is sometimes forgotten in th e ru sh to resuscitate the i nju re d patien t.
FIGURE 5 -25 A Ha re splint is u sef ul as a temp o rar y me ans of immo bilizing a fractur e of the femur or tibia by direct traction . It should be u se d only as a tempora ry splint and replaced by skeletal o r skin traction when the patien t ha s been st abilize d. (Modified from Connolly J. Fra ctu res an d dislocation s. Closed ma nagemen t. Philadelph ia: W B Sa unders, 1 995, with permission .)
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Skin Traction
Th e u se o f ski n tractio n to a lign a fr actur e, particularly of the femur, h as bee n co mm on since it wa s p opularized by Buck in th e Civil War (2 38). Skin tra ctio n is still used to day b ut only as a tempo ra ry me ans of stabilizin g a dult h ip fractures o r o cca sio na lly the femur fracture in a ch ild's leg. Skin i s u nabl e to tol erate more th an approximately 6 to 8 pounds of traction f or a brief length of time. H eavier or prolo nged tra ctio n te nds to pu ll off the super ficial layers o f the skin and can ca use p ressure necrosis of soft tissues (Fig. 5-26) (239).
FIGURE 5 -26 Skin traction can cause irritation of the skin, allergic reactions, or avulsion of the superf icial layers of the dermis . Standa rd adh esive ta pe sh ould be avoi ded sinc e skin ir ritation as illustrated here is fairly common.
P.1 74 Th e ba si c techniqu e o f Buck's skin traction is to a pply pa dding arou nd bony prominences o f the ma lleo li. Tract ion tape s are then applie d to the s kin and an elast ic ba ndage is w ra pped fr om the ankle to the kn ee. The end of th e ta pe is th en attached to the tra ction apparatu s (Fig. 5-27). Most co mm only n ow a p re packaged type of skin tra ctio n is ava ilable. It can be applied quickly and eas ily u sing spo nge- rubber mat erial t hat can be remo ved and r eapp lied o ften witho ut pe eling off the ski n.
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FIGURE 5 -27 Skin tra ctio n shou ld be appli ed o nly as a temp o rar y mea su re. The tr action is appli ed supe ri or to the mall eoli wit h tra cti on t apes a nd an elastic ba ndage wrappe d fro m th e an kle to th e kn ee. Avo id mo re tha n 6 to 8 po und s of trac tio n sin ce it ca n produc e skin irrit a ti on or skin necrosis.
Application of Skeletal Traction

Th e preferred me th od of a pplying tra ction for most fractures is by inserting a th readed Steinman n or Bonn ell pi n into the d ista l fractu re fragment and then appl ying tra ction weights di re ctly to it. In i nserting any sk elet al tra ctio n pin the skin m u st be preppe d as wit h any surgical procedur e. Gloves a re wo rn and the area is iso lated wit h to wels a nd sterile precau ti ons are ta ken. Usual ly the pin can b e in se rted un der lo cal anesthetic but o ften the patien t is u nder general o r spinal an esthetic. If a l ocal ane sth etic is u sed, the an esth esia sh ould be infiltrated do wn tho ro ugh ly to the sensit ive p eriosteum. The skin should be i ncised prior to inserting the tracti on pin to avoid irritation from the p in. A wide variety of traction techniques are a vaila ble th at allow t re atment of fra ctu res from th e cervical spin e do wn to the fo ot ( F ig. 5 -28). O nce th e pin is inserted, the limb is immobilized on some type of support. For the fe mur, this is most o fte n a Ha rris modif ication o f a Th omas splint w ith a P earson at tac hme nt (Fi g. 5-2 9). T he splint and tra ction weight are co unterbalanced by a weight a t the head of th e be d. The foot is kept out of e quinu s by a pl antar su pport. Th e Achill es tendo n mus t be well padded , and any bo ny pro minen ce s as w ell a s the peron eal nerve sho uld be pr o te cted. For f ractures at a proximal level o f th e femur, tra ctio n can be mo st ef fective if the limb is held in a 9 0 9 0 positio n, which mainta ins bo th th e h ip a nd th e kn ee flexe d 90 de gre es to correct the tende ncy of the proximal f emur to externally rotate and flex (Fig. 5-30).
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FIGURE 5 -28 S keletal traction sites. A variety of sites for ske letal traction are a vaila ble. The techn iques ra nge from traction in the ole cra non to skull traction as illustrated here. (Mo dified from C on nol ly J. F rac tur es a nd di slo catio ns. Cl osed manage ment. P hilade lphia: WB Saun der s, 1995, with perm iss ion.)
Hazards of Skeletal Traction

Alth ough skele ta l tractio n has be en proven to be a ver y reliable an d u se ful metho d of reduc ing an d ma intain ing alignme nt of many dif feren t fra ctu re s, it can o cca si onally be ass o cia ted with complications. Pi ns tha t are left in for more tha n a few weeks ca n be come sources of infection or me ch anica l irritatio ns o f nea rby ne rve s an d vessels ( 2 40). Pin tr act inf ection c an be mana ged by (a) h avin g the pin pas s thr o ugh the least amou nt of soft tissue possible, (b) m in imizing moveme nt of j oin ts adja cent P.1 75 to th e trac tion pin , an d (c ) clean sing th e skin -pin in te rface with peroxide an d appl ying a n antibio tic ointmen t.
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FIGURE 5 -29 A,B . Fra ctures of the femur ca n b e treated in a Harris splint. The e ntire system is co unterba lanced with weights proximall y an d dist ally o f appr oxima te ly 10 pounds. Lo ngitudin al skel eta l trac tio n is applie d thro ugh the ti bia or o cc asion ally th rough the dis tal fem ur. T he foo t is h eld o ut of equ inus by a pla ntar su pport t o avo id crea ting a tigh t hee l cord. The Ac hilles te ndon is well padded and all bon y pro minences are protected espec ia lly aroun d the per on eal nerve. The Pears o n a tta chment to th e splin t allows flexio n and ext ensio n of the kne e.
O ne of the most common complication s from skeleta l traction is overdistracting the fracture. This h as b een fo und t o occur p art icularly in frac tur es of the distal radius wher e ligam en to taxis from externa l fixation can be ex erte d too vi gorou sly. Overdistraction of the radioca rp al j oint then lea ds to stiffness a nd even c ausalgi a o f the fin ger s an d hand (241 ). The te ch nique o f ske letal tra ctio n fo r cervic al s pine i njurie s can also o verdistra ct if the metho d is applied to o vigo rously or without careful monitoring of i ts effect (16 1,16 2,2 29).
FIGURE 5 -30 A 9090 system of traction is quite useful for reducing fractures of the proxi mal femur. Th e l imb can be positioned to correct the tendency of th e proximal femoral fra gment to flex and externally rota te. It illu stra te s the principle that tra ction sh ou ld bring the distal fragme nt into a lignment with the proximal fragment of a fra ctu re. (Modified from Conn olly J. Fra ctu re s an d dislo ca tion s. Clo sed man agemen t. Ph iladelph ia: W B Sau nders, 1 995, with perm iss ion.)
Techniques of Cast Application

A plaster-of-paris cast is useful to immobilize most fractures, whether treated n onoperatively o r o perat ivel y. Co mplicatio ns tha t can be associat ed wit h c ast applica ti on range fro m l oss o f lim b to i tch y skin. In fections (including gas gangrene), isch emic muscle necrosis from compartment syn drome, and unreco gniz ed vascular inj uries can be hidde n u nder a cast and lead to loss o f lim b (2 42). One shou ld be particula rl y cau tio us in applying cas ts to patien ts with loss o f protective sen sation du e to con dit ion s such as dia betes o r a hea d in jury. Th is can lea d to rapid skin bre akdow n from pressure n ecrosis (Fi g. 5-3 1) (243, 244). Be fo re ap plying a ca st, the cir cula tory, mo tor, a nd se ns ory sta tus o f the l im b sho uld be che cke d to d ocumen t if the patien t ha s an y evide nce of neu rolo gic inj ury. If there is a ny ques tion o f ci rcu latory l oss, the cast sho uld no t be applied un til the circu latory stat us is clarifi ed a nd circula ti on is resto re d. Since the limb swells after th e fracture, i t is important to e levate it in the cast to allow dra ina ge from th e ex tremity. If th e pa tient complains of pain from the ca st being too tight the cast should be bi -
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v alved and the ca st paddin g relea sed do wn to th e skin t o relieve the tightness. Edema fluid that persists in the hand or the foot can produce a glue-like effect, impeding the syn ch ron y of motion bet we en te ndon s, bo nes, a nd join ts. Enco uragin g active motio n of the fin ger s, toes, a nd a ny muscl es in the inju red ex tremity is the mo st effective me th od of minimizing functi onal i mpair ment and preventin g ca st disease. Th e pla ster-o f-paris ba ndage con sists of a roll o f muslin stiffe ned by a s tar ch a nd impre gnated wit h a h emihydra te o f ca lcium su lfa te . Wh en water is added, the ca lcium su lfa te crysta llizes ( C aSO 4 H 2 O + H 2 O = CaSO 4 2H 2 O + h eat) . The setti ng P.1 76 of this material may be a ccelera ted by increasin g the temperature of th e water or slowe d by cooling th e wat er. The cry stallization o f plaster-of-pa ris is a n e xothermic reaction (245).
FIGURE 5 -31 A cas t was a pplied f or an an kle sprai n in thi s patien t with lon g- stan ding diab etes. Breakdo wn of th e skin an d sur ro undin g sof t tissues was e vident when the cast wa s remove d at 1 week. The loss o f protec tive sensatio n i n th is patien t was no t appreciated, an d the c ast treatment considera bly le ngthen ed the treatment, although f ortuna tely the o utcome was satisfa ctory.
Th e pla ster cas t is applied in layer s by mol ding wit h th e ba se o f one 's han d (Fi g. 5- 3 2). As the cas t is a pplied and the plas ter-of-pa ris cry stal lizes, the hea t given o ff can be eno ugh to burn the s kin (2 46). Th is is e spe cia lly l ikely i f the w ater u sed to soa k t he plaster w as h ot to the tou ch (F ig. 5 -33). The p laster ban dage shou ld be immersed in a wa ter bath that is a t room temperatu re or at least co mfo rt able to th e to uch of the per son wh o is applyi ng i t. This is tru e w hether on e is applying a circula r cas t or a lo ngit udin al spl int. In fact, many thick splin ts m ay produce even high er ex othermic
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tempera tures than do ci rcu lar casts. A nu mber of se ri ous p roblem s ca n develo p wh enever an inj ured o r eve n u nin jured limb is imm obili zed i n a cast or a ny device. On e sh ould particula rl y avo id prolo nged use of an tish ock g arm ents, or a pplying cas ts that are likely to pr o duce isch emic in jury to underlyin g str uct ures i ncluding skin, n erves a nd ves sel s (Fig. 5-34 ). C asts an d splin ts that imm obilize limbs i n a n onfun ctio nin g po sitio n, sh ould be avo ided, e spe cia lly for mi nor inju ries. F or e xample, a posterior spl int a pplied f or an an kle sprai n sho uld no t lea ve th e foot a nd ankle in t he equin us po sition . This ma kes it imposs ible for the patien t to bear any weigh t on the l im b, promo tes ede ma, a nd de lays rec o ver y f rom the min or inju ry ( Fig. 5-35 ). Pro lon ged la ck o f fun ctio n c an r esult in dis use osteo poro si s of th e foo t an d subsequ ent pain wit h weightbea ring (247, 2 48 ). Ca sts a pplied to the u pper limb sho uld a llow mo ti on of th e j oints of the fi nger s. Sim ila rl y cas ts o n the lowe r limb sh ould not impin ge o n or block t oe motio n. Th e pa ti ent's compla ints of a painf ul cast sho uld be h eeded and the cast chan ged pro mp tly. Of ten t his ma y reve al an area of ea rly skin pressure o r irr itatio n that mi ght we ll advance to full -thi ckn ess skin l oss. Some patients who re peatedly request cast ch ange s might be better tre ated by ope ra tive frac tur e fixa ti on. A variety of casting produ cts have beco me ava ilable as a su bstit u te for th e clas sic p laster-of-paris ca st (2 49, 250). Th e mo st widely used is a knitted fibergla ss fabric , which is i mpre gnated with p olyureth ane r esin. Exposu re o f th is pro duc t to wat er initia te s a ch emical r eaction , whi ch c au se s the ta pes to become rigid. Th ese ma te ri als h ave th e advanta ge over pla ste r of be ing re latively l ightweigh t, strong, ra diolucent, a nd, wh en properly used, re sistan t to water. Th e ma jor clinical d isadvanta ge o f fibe rgla ss is tha t it ca nno t be molde d to the limb a s well as can plas ter. A se co nd d isadvanta ge is th at th e po lyur etha ne resin w ill adher e firmly to unpro te cted skin and to clothin g. Th erefor e, pro te ctive glo ves s hould be w orn while ha ndlin g the material, an d care shou ld be e xer cised to avo id co ntac ting unpro tecte d area s o f th e pa tient's s kin durin g ap plication . Swabbin g l ight ly w ith a lcohol or a cetone m ay help in removin g uncured re si n from the ski n. If t he patient is l ikely to immerse the ca st in water, th e e xtremity should be first wrapped in a w ater-sh edding sto cki nette. Oth erwis e the un der lying cast padd ing ma terial will rema in so ggy under the ca st and ca use skin irritatio n. Th e fiberglass cast material is a pplied a fter fracture reduction is accomplished. One or two laye rs of sto cki nette ar e a pplied over th e li mb and cast pa dding is adde d over bony pro mine nces. The cast tape is immersed one roll at a time in water at room temperature and carefully applied using glov es to p rotect the skin. Th e u su al se tting time for the materia l is approximately 3 minutes. This ca n be l engthened by removi ng th e roll wi th ou t squeezing it or by using cooler water. The cast is wrapped spir a lly, o ver lappin g ea ch turn o ne half to two thirds the w idth o f the tape. Th e mater ia l is less flexible tha n th e u su al plast er-of-paris and theref ore less mo ldable aro und the limb, but stil l is su itable for mo st sta ble fractures th at do n ot requ ire th at the cast be closely contoured. T he fiber gla ss material sets fa ste r than pla ster -o f-paris, a nd w eightbearin g may usua lly be al lowed once th e cast has dri ed tho rou ghly. If the patien t compla ins o f an y dis comf ort followi ng ca st applicatio n, i t i s best to remove it to ch eck for pressu re sores or othe r problems. The ca st may be bi-val ved to a cco mm oda te for acute swe lling, and then a new cast appl ied once th e swe lling su bs ides. Fibergla ss ca st remova l requires an osci llating type of saw th at ge nerates dust tha t is lower in q uantity and larger in particle size than the dus t ge nerated on remo val of pla ster- of-paris casts . This d ust usua lly consists of glass fibers embedded in cured P.1 77 p olyureth ane wit h a mino r amo unt of gla ss fibe r dust. The y are no t con sidered to be respir able-sized p article s and fall well below the perm iss ible oc cupatio nal expo su re limits for nu isanc e dusts. The ca st sa w mu st be u sed carefully to avoid lace ra ting th e skin un der the cast. It is best to support the ca st w ith th e thu mb he ld a gains t th e cas t in order to a void pus hin g the blade thr o ugh the patients' skin (Fig. 5-36).
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FIGURE 5 -32 A. A plaster-of- paris ba ndage is applied ca re ful ly o ver the cast pa dding. Th e roll is applied by the fingertips with the ban dage co nforming to the circu mferen ce o f th e a rm or leg. The roll may be redi re cted by ta king tu cks as illus tr ated w ith the lef t h and of the cast tec hn icia n in th is demo nstration . B. When th e ca st is complete d and the plaster is still wet the struc ture o f the cas t is m o lded to the co ntou r o f the l eg u sin g the pal ms of th e h ands. Avo id an y finger tip pressu re tha t can cause pressure po ints u nder the ca st and subs eque nt skin ne cro sis.
Th e u nder lying cast pa dding is cut do wn to the sk in u sing b andage scisso rs wh ile a cast sprea der spreads the cast edges (Fig. 5 -37).
Reduction by Restoring Joint Axis of Motion

Fractures occur by either direct or indi re ct mechan isms (34,109,230,2 32 ,251 ). Examp les of indirect me ch anisms include the patient who f alls on the ou tstr etched han d fractur ing the sh oul der o r the skie r who twis ts th e le g f ixed in the sno w a nd frac tures the tibia (25 2). D ir ec t mec ha nisms a re typified by the motorcycl ist who sustains a comminuted open tibial fra ctu re f rom a direct blow to th e l eg a t high speeds . Reductio n techn iques shou ld reve rse the mechan isms producin g the o ri ginal d eformity rather than accen tu ate th em. The skeleton is least able to resist torsional loading (231, 251). Yamada (253) found that the u ltimate tors ion al strength of bone is onl y one th ird that of its compressive strength a nd one half th at of its tensile strength. Whe n a u niform skeleta l specimen is su bjected to to rsional testing, it fails i n a co nsiste nt pa ttern. The most significan t determinant of this fracture pattern is the direction o f l oadin g. The patter ns of to rsio nal f ailure are complet ely predic table and reprodu cible. F ailu re o ccu rs first in the cortex, w hich is subjected to maximum tensile loading. The fracture then spirals over to the opposite cortex in a clockw ise or cou nterclockwise direction . Reve rsing this mechan ism of failure ca n o ften res tore alig nm ent to a dis pla ce d f racture ( 23 2, 254 ). R otational deformities m ay be cosmeticall y unsatisfactory, but, more i mportantly, they are often d etrime ntal to f un ctio n because they cre ate a misalign ment of the jo int axes o f motio n. Reductio n technique s shou ld first recognize th e torsiona l mecha nisms
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P.1 78 th at pro duc ed th e fractur e and dis to rt jo int align ment. T he techni ques o f reduc tio n sh ould be dir ecte d a t reversing these torsion al mechanisms, particularly in order to restore al ignment of the joint axis of mo tion .
FIGURE 5 -33 Wh en plaster is applied it produces a n e xothermic release of heat. If the water in which the plaster is soa ked is too h ot, thi s combination can burn the patien t's skin. This illu str atio n s how s a th ird- d egree bu rn of a patient afte r a cast wa s applie d with water that was well abo ve ro om tem perature. Even pla ster splints h ave been ass ociated occasio nall y with t his complica ti on if the water used to set th e ma terial is uncomfortably hot.
A typical example of a fracture produced by indirect loading is seen in the patient who falls on the outstretch ed h and, internally twi sting the arm while loa ding the sh ou lder. This produces a fracture of th e proximal humerus with a fairl y con sistent spiral oblique pa tte rn. The fra ctu re lin e ru ns from th e d ista l late ra l co rtex to the proximal media l co rtex due to the internal torsion of the hu merus fixed in th e gle noid (Fig. 5-38 ). Immo bilizin g such a fractur e, whic h was produced by i nternal rotatio n, in a slin g, wh ich fur ther interna lly ro tat es the dis tal fragm e nt, r epr o duc es the origi nal mechan ism an d ten ds to dis place the sh af t fra gment me dially (Fig. 5 -6). A h um er al fra ctu re o f this type is redu ce d by ro tat ing the sh aft fra gm ent outwa rd. One can t hen emph asize ea rly mo bilizatio n of the sho ulder and a rm rathe r than immo bilizatio n of the arm again st the ch est. Co nver sely, the humera l frac tu re re su lting from an externa l torsional load on the extended arm has th e opposite mirror image fracture p atte rn: the fra ctu re line run s from th e distal medial cortex upward to the proximal latera l cortex. Th is externally rotated fracture is best reduced by immobilizing the shoulder with interna l rotation a nd a slin g. F ollowing a brief perio d of immobiliza ti on, a humera l fracture slee ve can be applie d to a llow active elbo w mo tion an d utili ze functio n of the mus cles a nd j oin ts arou nd the f rac tur e to ma intain the no rm al axis o f the elbo w joint.
Forearm Fractures Reduced by Reversing the Mechanism of Injury

Fo re arm fractures result from failure in compression or tension or both. Compre ssion fa ilure produces th e characteristic torus fracture of the child's dista l ra dius, or the impacted Colles fractu re in the
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o lder adult. Both types of co mpression f ra ctur es occu r in relatively un derm inerali ze d bo ne in thes e a ge gro ups. To rsi ona l, in direct loa ding is also a frequen t cause of f orea rm f ra ctu res inclu ding th e g re enstick fra ctu re in the child and the dis plac ed radial shaft f rac tu re in the adu lt. Here the me ch anism is a fa ll on the outstr etched arm twis ting the forearm bo nes, whic h fa il in to rsio n. Th e u sual positio n of the forearm at the time of frac tur e is in supina tio n ( Fig. 5-39) . Th is cau se s the g re enstick fractu re a s well as th e a dult sh aft fractur e to angu late in a vo lar dir ecti on. If th e fall o ccurs wit h the fo rearm prona te d, the torsion al mechan ism produ ce s a frac tur e that angu lates d orsally. To reduce these fra ctu re s, the torsion al me ch ani sm shou ld be reversed. Th is is done not by h yperextending or h yperflexing the deformity but reve rsing either the supinated or pronated forearm. Th us, the fra ctu re with vo lar a ngula tion is u sually corrected by pron ation . The f ra ctu re with do rsa l a ngul ation is co rrecte d with supin ation . Th e ma jority of forearm fractu re s are produ ced by direct trauma, which can be quite violen t. The fun ction that is most sig nifi ca ntly i mpa ired w ith forea rm fra ctu res is th e u nique rotatory motion (supin atio n/prona tio n) necessary f or positio ning of th e hand. Th is requ ire s rotatio n of the radiu s an d n ot of the uln a. Fortu nately, loss o f forearm prona tion can be co mp ensated by sh ou lder abdu cti on. Lo ss of supinat io n, how ever, is poo rly comp e nsated by the sho ulder. Th e forea rm normally is able to rota te 120 to 140 de gre es. The norma l lateral b ow of the radius p ermi ts it to clear the soft tissu es of the fo re arm as it rota tes around the uln a. It is important to ma intain the no rm al ra dial bow an d the intero sse ous sp ace requ ired for rotatio n o f the radius. A frac tur e that produc es loss o f the norma l radia l bow ca n lead to l oss o f rotatio n. It i s also im po rta nt to remembe r that the interosseous space is grea test in neutra l rota tion and na rrowest i n full p ro na tio n ( 255, 256). Ma intain ing ext re me pro natio n during fractur e hea ling can cause some p erma nen t stiffenin g of the mu scle s and inte ro ss eou s ligamen ts, which in t urn will limit supin atio n o f th e forea rm. Therefore, forearm fractures should usually be immo bilized in e ither su pination or in n eutral rotation. C losed reduction is the treatment of choice for fracture of the forearm of the child except for the o cc asion al Mo nteggia P.1 79 frac tur e-dis loca tio n of the elbo w. C losed reduc tio n o f adu lt for earm fractur es has also been standa rd fo r tho usands of yea rs. Shan g et al (2 56 ) and oth ers (255 ) in Ch ina ha ve sho wn that tra dit ion al b onesetter methods of redu cing th e forea rm fra ctu re s in adu lts can be qu ite safe and effec tive. H oweve r, because closed reduction is considered somewh at de manding an d u npredictable, most o rt ho paed ic su rge ons prefer ope n redu ctio n and intern al fixatio n of f rac tur es o f both bo nes o f the fo re arm (25 7, 258). Neverthele ss, it is still worth con si dering clo sed me th ods th at ca n a void co mp licatio ns such as inf ectio ns, pa inf ul sca rs, and the need to su bs equen tly remo ve pla te s, wit h the p ossibility of refra ctu re (10 ,259,260,26 1,262). P atients with rel atively th in fo rearm s as well as youn g w omen wh o do not des ir e a scar on the fo rearm ma y be of fe re d a trial of clo se d reduc tio n. I t sh ould b e under stoo d tha t if r educ tio n is lost or a ngul ation is unaccept abl e, dela yed o pen reduc tion c an be p erforme d without affecting good results from operative treatme nt (258).
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FIGURE 5 -34 A va ri ety of pro blems ca n develop af ter app lica tion o f any type of im mobil ization device t o an inj ured li mb . A. Pa tients should be ca refu lly monitore d for th e problems ill ustra ted he re , inclu ding a co mp art ment syn drome after prolonged use of a n a ntisho ck garmen t in this patien t with multiple f ra ctu res. B. Pressure necrosis a fter a ca st application with excessive pressure over the b ony prominence of the proximal fragment conv erte d a closed tibial fracture to an open fracture. C. U lnar nerve palsy re su lted from ca st immobi lization of a fractured forearm with th e elbow fle xed bey ond 90 degree s. This c au sed the patien t's mobil e ulnar nerve to ride over the h umeral epic o ndyle resulting in isch emic n europa thy of the nerve with loss of intrin sic function o f th e h and. An imp ortant principle t o follow whe n imm o bilizin g the elbo w is to avo id position ing it beyo nd a righ t an gle, w hich incr eases th e risk of isc hemic ulna r ne uropa th y.
Technique of Closed Reduction of Forearm Fractures

C losed reduction of the forearm fracture is performed with th e pa ti ent u nder either a ge neral or re giona l a nest hetic . T h e pa tie nt P.1 80 l ies supin e wi th fingers on the fractur ed side su pported in a f inger tra cti on appara tus ( Fig. 5-40 ). C ountert raction is a pplied with a we ighted slin g pu lling on the arm. Th e elbow is flexed 90 degrees a nd th e fore arm supin ated. T h e tractio n is mainta ined for 5 to 10 min utes to regain the ne ce ssa ry l ength of the f orearm and to c orrect a ngula r deformity. After the leng th is re stored, the surgeon re duc es the fra ctu re by squeezin g on th e volar and dorsal mus cle ma sse s bet ween the radiu s an d
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u lna , forc ing th ese two bones apart (Fig. 5-4 1). The f orearm is rota ted sligh tly to promo te i nterlockin g of the fr actur e fragm e nts, an d correct ro tat ion al alignme nt is judged radio graphic al ly by comparing the width of the cortices of the proximal and distal fra gments (263).
FIGURE 5 -35 A. Avoid imm obili zi ng li mbs in malf unctio ning positio ns especia lly a fter minor inj uries to th e foot or an kle. Thi s illust ratio n shows a fairly typic al ankle s prain that was referre d from th e e me rg ency de partment in a posterior splin t. It fa iled to su pport the an kle and all owed it to drif t into eq u inus. B. Swe lling and disus e changes were evident when t he patien t returned for follow -up at 1 w eek.
Th e goal of close d or open re duction is to restore the skeletal anatomy of the forearm as co mpletely a s possible. However, the f orearm can accommodate a moderate amou nt of stru ctu ral alteration since sh ortenin g of the upper extre mity is ge nerally tole ra ted mo re a nd is less functio nally signif icant th an i s shortening in th e lower limb. This is true for fractures of both the humeru s an d the forearm. If the ra dius sh ortens m ore th an 5 to 7 mm, it is likely to be a sso ciated w ith disruption of the distal ra diou lnar art iculatio n. Alt h ough so me a ngula ti on of th e forea rm fra ctu res can be accept ed wit h out i mp airing rotatio n, a ngula tion o f gre ater tha n 15 deg rees ca n limit ro ta tion an d may also be cosmetica lly unacceptable . Th e radi al bow sh ou ld be restored to a llow the normal re tu rn of rotation. Th e u lnar fra ctu re is usually re duc ed en d to en d, alt h oug h sligh t o ver ri ding i s accept able. Angula tion o f either th e ulna or the ra dius o f les s tha n 10 deg rees dorsally or vola rly has not be en found to affect functio nal ou tcome (264). Sch emitsch an d Rich ards (26 5) devise d a method of directly measu ring th e ma ximum ra dial bow (Fig. 5 -42) and dem on stra te d tha t even wit h the use of pla te fixat ion ma lunio n can be a pro blem if t h e ra dial bow is n ot corre cted. They reported th at restoration o f th e n ormal radial bow is particularly i mp ortant to a go od function al outco me. Mo re tha n 8 0% retur n of n ormal rotatio n of t he forearm was a ssoc iated with th e restora tion of th e ra dial bow. Also, resto ra tion of g rip strength was a ssoc iated w ith th e restora tio n of th e radia l bow to ward no rma l. This radio graphic t ech nique o f me asuring the n ormal radia l bo w in term s o f m agn itude and locat io n of the maxim u m bo w co mpared wit h th at o f t he oppo site normal fore arm should be k ept in mind with either non ope ra tive or operative tre atment (F ig. 5 -43). When the radia l bow is restored cl ose to that of the unin jured extremity, the range o f motion o f the forearm and grip strength are also close to no rma l. An alteratio n of the no rm al r adial bow th erefore a ppears to be of gr ea ter functio nal significance th an is do rs al or vo lar angu lation o f less
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th an 10 o r 15 de gre es (26 4). O nce sa tisfactory align me nt is achieve d, a lon g a rm cast is P.1 81 P.1 82 a pplied. Whil e applying th e ca st, it is ke y to m ain tain the re duction by moldin g in t he inter o sseo us spa ce bet wee n th e radiu s an d u lna. The fore arm is maintai ned in su pinat io n or neutral rotatio n. Th is k eeps the intero sse ous spac e and l igam ent at ma xim um width a nd te nsion . Red ucti on is co nsidered i nadeq u ate if the ra dial bow is lo st, the interosseo us spa ce bec o me s na rro wed, or angula tion o f th e fo re arm bo nes exceeds 1 5 d egrees. I f the re duc tion is l ost a fter ca st applicatio n, th e f rac ture ca n be re ma nipu lated o r o pen reduc tion a nd i nternal fi xation can be carr ied o ut.
FIGURE 5 -36 If a pa tient co mplain s of a ny disco mfo rt f rom a cas t, it is bes t to rem o ve it an d check for pressure sores and other problems. Th e cast sa w that is commonly u se d for cu tting plaster is generally safe but can cut skin. The cast saw should be supported with the thumb aga inst the cast to preven t the blade bein g push ed thro ugh the patien t's ski n and ca using a deep laceratio n. (Mo difie d from C onnolly J. F rac tur es a nd disl ocatio ns. C losed mana ge ment. Ph iladel phia: W B Sa unders, 1995, with pe rmi ssio n.)
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FIGURE 5 -37 Once the ext ernal plas ter i s cut th e under lying cast pa dding i s also cut using a safety bandage scisso rs an d spreading the cast edge s with a ca st spreader as ill ustra ted h ere. (Modified from Connolly J. Fra ctur es and dis loca ti ons. Clo se d man agemen t. Phi ladelph ia: W B Saunders, 1995 , with permission .)
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FIGURE 5 -38 A. A commo n mechan ism produ ci ng a f rac tur e of the hume ru s is a fall on t he o uts tretc he d ha nd, w hich locks th e humeral hea d in the shou lder a nd internal ly ro ta tes the arm . B. The re su lt is a failu re o f the proxim al hu mer us wit h the fra ctu re lin e run nin g f rom th e dis tal later a l to t he proxima l medi al co rte x. The shaf t fragment te nds to displace medial ly (s ee Fig. 56 ). (Mo difie d f rom C on no lly J . F rac tur es a nd dislo catio ns. Cl osed manage ment. P hilad elphia: WB Saunders, 1995 , with permission .)
FIGURE 5 -39 A. A fre quent indirect me ch anism fractur in g the forearm is a fall on the o uts tretc he d arm wit h forcef ul supina tion . This pro duc es a frac tur e w ith volar angu lation du e to vectors from the floor reaction force th at mo ve up th e forea rm dorsal ly. B. If the forearm is forcefu lly prona ted at the time of inju ry , a fracture results tha t angula tes dorsally due to vectors from the floor reaction force th at mo ve up th e forea rm volarly. (Modified from C onnolly J. F rac tur es an d dislo cation s. Clo sed ma nageme nt. P hilade lphia: WB Sa unde rs, 1995, with permission .)
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FIGURE 5 -40 The te ch nique o f closed re duc tion o f fo re arm f rac tures u nder a regio na l o r gen eral anesthetic utilizes trac tio n applied dis tally and proximal ly to the forearm . Th e pa ti ent lies supine on a fracture tabl e ( 1 ) wit h th e fingers held in a finger tr acti on appa ra tus (2 ). Counte rtraction is applie d with weigh t on th e u pper arm ( 3). T he elbo w is flexe d 9 0 de gre es (4). The forearm is supin ated usuall y to achie ve ro tat ion al re alignmen t ( 5 ). Trac tio n i s main tained for 5 t o 1 0 mi nutes to r ega in length. (Mo dif ied f rom Co nno lly J. Fractur es and disloca tions. Close d man agemen t. Ph iladelph ia: W B Sau nders, 1 995, w ith perm iss io n.)
Th e cast may have to be changed sever al ti mes as th e pa tient is fo llo wed ca re ful ly po stredu ctio n. If a deq ua te reduc tio n ca nno t be main ta ined during the early sta ges o f tre atm ent, su rgic a l inte rve ntion sh oul d be rec ommen ded. Ho wever, sligh t loss of redu ctio n in the ca st may be accepted (Fig. 5-44 ). Durin g this hea ling ti me a wrist brace may be in corpo ra ted in to th e long arm c a st to encou rage acti ve finger and wrist functional motion while preventing forearm rotation (258). At 4 to 6 weeks, the cast ma y be replac ed by a functio nal brace. Th e a verage ti me for heali ng o f displaced two-bone fract ures of the forearm by closed method is 15 w eeks . Clinical uni on, eviden ce d by absence of pa in a nd fracture sta bility, usu ally occurs be for e ra diograph ic h ealing . A cast or brace sho uld be co ntinu ed u ntil th e fractur e is con so lidated on the xra y. The patien t sho uld be en coura ged to ac tively exercis e th e fingers and mus cles of the for earm d uring th e pe ri od of he aling to minimize soft tissue sca rring a nd mu scle con tra ctu re. This also mi nimiz es th e resulta nt functio nal imp airm en t whe n i mmobiliz a tio n is discon tinued . P.1 83
Closed Treatment of Isolated Distal Radial Fractures

An isolated dista l radial shaft fracture may be produced by a direct blow to th e radius, a commo n me ch anism also for iso lated fractur es of the uln a. In the early 20 th c en tu ry these wer e called chau ffeur's fractures becau se they were most commonl y sustained when the fore arm was struck while cranking a motor car.
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FIGURE 5 -41 A. After th e traction has restore d the length o f the fore arm, the reduction is achieved by directly ma nipul ating and rotating the forearm to i nterlock fracture fra gments in a correct rotation al alignme nt. B. The su rgeon applies a cast a nd molds or compresses th e intero sse ous spac e to ma intain the intero sseo us ligament at ma xim um te nsion . This provides importa nt support for th e fracture fragments proximally a nd dista lly. (Modified from C onnolly J. Fra ctu res an d dislocation s. Closed ma nagemen t. Philadelph ia: W B Sa unders, 1 995, with permission .)
FIGURE 5 -42 According to Sch em it sch an d R ich ards, to measu re the radia l bo w a lin e is drawn from th e bicipital tuberos ity to the most ulnar aspect of the radius at the wrist. A perpendicular lin e (a ) i s then drawn from th e po int of maxi mum r a dial bow to th is lin e. The hei ght o f the perp en dicular line (th e ma ximum ra dial bow) i s measured in millim eters. Th e distan ce fro m th e bic ipit al tubero si ty to t he pre viou sly measu re d perpen dic ular line at th e po int of maxi mu m radial bow is then measured. It is recorded as a percentage of the length of the entire bow. This measurement is termed the location of the maximu m radial bow. Th e measu rement X/Y tha n 80% of n ormal valu e w ere fou nd to h ave dim inished rota tio n and grip str engt h . Resto ration of norma l radial bow is related to restoration of forearm rotation a nd gri p strength. (Modif ied from Sc hemitsch E, Ri ch ards R. The effect of malun ion o n fun ctio na l outc ome afte r plat e fi xation o f fractur es of bo th bo nes of the forea rm in adul ts. J Bon e Jo int Su rg 19 92 ;74A:10 68 10 78 , with permission .) 10 0 is co mp ared wi th the same measureme nt on th e op posite uni njure d arm. Patien ts with less
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Isolated di stal radial shaft fractures from a direct blow u su ally are not associated with disruption of th e interosseou s membran e or injury to th e distal radioulnar joint. These fractures are usually sta ble a nd ca n be treated effectively by clo sed meth ods. Initia lly th e frac ture is mana ged by imm obi lization i n a lo ng arm c ast in neutral rotatio n fo r 2 to 3 weeks. Th is main tains th e interosseo us space and a llow s the fracture to begin hea ling with minimal limitatio n of pronatio n o r supi natio n. Follo win g the i nitial per iod of long arm ca st immobi lization , the fra ctu re is th en held in a fractur e brac e th at sho uld a llow the patien t to begin some wrist and hand funct ion . The usua l tim e for he aling of th e iso lated frac tur e of the dis tal radius wit ho ut dis tal radio ulna r joint inju ry is be tw een 10 an d 12 weeks.
Colles and Other Fractures of the Distal Radius Produced by Indirect Mechanisms
C olles fra ctu re is typ ica l of the pattern of fra ctu re of osteoporotic bon e in postme nopausal women (2 66). Th e same hype re xtension P.1 84 me ch anism producin g a Colles fractur e in the older woma n is likely to produce a fractur e of th e carpa l scaph oid in the you ng ma n. Simila rly, hy p erextension in jury to th e ch ild's wrist pro duces a fra ctu re o f th e distal radia l epiph yses or a torus fracture of th e radial metaphysis. This variation is due to the d ifferences in bo ne density amon g the se groups.
FIGURE 5 -43 A. Ant eropo ste ri or and lateral x- ra ys sho w ma lunio n of a frac tu re o f the radius for w hich corrective oste otomy was recommend ed. Many such an gulatory deformities ca n be corrected by simple drill osteoclasis and closed re-re duction of the fracture. B . X-rays after corrective osteotomy and plate fixation sh ow that vola r angulation was co rrecte d but the ra dial bow wa s decreased. Th is left persistent impairment of rotation of the fore arm.
H yperextens io n-compres si on inj ury u sually produ ce s a typica l din ner- for k deformity, includin g an a brupt do rs al pro minen ce of the dista l radiu s an d carpu s an d a rou nded vola r promin ence fro m the p ro xim al radial fra gm ent. W ideni ng o f t he wrist is a result of a rela ti ve displa ce me nt o f t he ulna a nd ra dial deviatio n of the ha nd. The reduc tio n ma neu ver s ho uld be di re cted at co rr ectin g the se pro blems (Fig. 5-45). Th e meth od of reducin g the fra ctu re is to re ver se the origin al mechan ism of inju ry (whic h was usuall y h yperext ensio n and supina ti on of th e wrist) . Af te r adequ ate anesthesia is achieved, an as sistant h olds the elbow an d offers c ou ntert rac tion whil e the surgeo n, h oldin g th e in jured han d, as if s hakin g
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h ands , applies tra ctio n and also direct pressure wit h t he th umb and han d on th e di stal fra gm ent. Th e fo re arm is su pinat ed an d he ld with t he surgeo n's o pposit e han d. Increasing the dorsal angu latio n w hile mainta ining the supina te d po si tio n disimpacts the fra ctu re fra gments . Followin g disimpactio n th e reduction is achieved by pronating the forearm a nd wrist. T he wrist is then directed into ulnar d eviatio n and slig ht f lexio n (F ig. 5 -4 6). Be ca use a co mm on complica tio n of C olle s fra ctu re s is wris t swe lling, it is be st to avo id immedia te a pplic atio n o f a cast until this swelling subs ides. Th e pref erred in itial imm obiliza ti on is wi th a suga rto ng splint wra pped circ umf erent ial ly wh ile th e a ssis tan t ho lds t he wrist in flexio n and ulna r devia tio n (F ig. 5 -47) . On ce the suga r-ton g splin t is a pplied, x- rays are ta ken to evalua te the reduc tio n. If t he re duc ti on is n ot sa ti sfactory, a seco nd manipu lation ma y be carr ied o ut, but repea ted man ipula ti ons sh ould be avo ided (2 67). Th e splin t allows for swelling, which might othe rw ise compro mis e circ ula tion . If th ere i s any evide nce of c ircu lato ry imp airm en t, the splint sh ould be loo sened and t he p adding removed do wn to t he skin. The patient is advi sed to keep the arm ele vated a nd apply ice to the wrist. A follow-up evaluation should be carried out in 1 to 2 days to ensure that the patient is co mfo rt able and the spli nt h as n ot be co me e xce ssive ly tight. In 7 t o 14 da ys the fractur e can be re x-rayed and a short arm cast ca n u sually be applied. After P.1 85 P.1 86 6 w eeks , clinica l healing is u sually present or at lea st sufficient to allo w a cha nge from a c ast to a co mmercial wrist splint. During the recovery period, the patient is encoura ged to actively exercise th e finge rs and sho ulder on the inju red side to avo id stiffness. Prolo nged use of a sling for mo re tha n 1 w eek sh oul d also be avo ided sin ce thi s tends to stiffen the sho ulder and inhi bit restoratio n of ha nd fun ctio n. Prolo nged failure of th e pa tie nt to resume active han d an d sho ulde r fu nction can lea d to sym pa th etic dystroph y ( 24 1,24 7,2 68).
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FIGURE 5 -44 A. Anteroposte ri or a nd lateral x-ra ys show a two bone fracture of th e forea rm for wh ich the patien t reque sted closed treatment to avoid scarring of the forearm. B. C losed reduc tio n was a cco mp lished, but the o ri ginal end -to -end con tac t of the ra dial fragm en ts was lo st and the fractur es settl ed in to b ayon et ap position . This was a ccept ed since the ra dial bow was not sig nificantly diminish ed. C. X -rays at 1 0 weeks sh owed satis fa ctory h ealin g o f th e fra ctu res wit h bayo net apposit io n of the radiu s an d en d-to- e nd a pposit io n o f the ulna . D ,E. F ollow-up clin ical photo graphs at 16 weeks s h ow the p atient with e ssen tially full supin ation a nd slight limitation of pron ation 6 weeks after the cast was remove d.
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FIGURE 5 -45 The Colles fractu re pro duces a typical dinn er- fork deformity, wh ich in cludes a n abru pt pr omin ence of the dis tal radius and carpus ( 1 ), and a roun ded vo lar promine nce from the proxima l radi al fragm en t (2). Widenin g of the wrist res ults f rom a dis pla ce ment of the uln a an d radia l de viat ion o f t he han d ( 3, 4). (Modif ied from Conn olly J . Fra ctu re s an d dislo ca tions. Cl osed manage ment. P hilade lphia: WB S aunde rs, 19 95, wit h per mission.)
W hile more unsta ble fractures, pa rti cu larly intraarticular fra ctu res, of th e distal radius may re quire mo re th an c losed reduction an d splin t applic a ti on to avo id settling and dis placemen t of th e join t su rface (236 ,269 ,27 0,27 1,27 2), the vas t majo rity o f Col les f ractu res in elderly pat ien ts can be ma nage d by th is stand ard c lo se d red uctio n te ch nique follo wed by a minimu m perio d of c ast i mmobiliza tio n. Th e techn ique is n ot complication free, a nd th e pa tient sh ould be ca refu lly mo nito re d for pro blems su ch a s median n europa thy, rec u rren ce of the defo rm ity, stiffenin g of the hand, and sympathetica lly me diated pain problems (248,266,267,273). Early decompression of the media n nerve in symptomatic p atients a nd th e use o f im mobiliza tion t echni ques th at do n ot in hibit functi on of th e hand and sh oul der may prevent the most frequent of th ese problems. The proble m of loss of, or incomple te , re duc ti on (272) ha s prompted a num be r of i nno vative att empts to im prove align ment by externa l fixation or internal fixation methods. Ironically, as the treatment of Colle s fra ctures has become more i ntense, problems of pin trac t in fec tion , f rac ture th rough pin sit es , s tiff enin g, a nd e ven ca us algia o f th e limb ha ve in cre ased (24 1), pa rti cu larly when the techniqu es o ver dis tra ct the fractur ed radius and w ri st.
CLOSED REDUCTION OF LOWER LIMB FRACTURES Closed Reduction of Calcaneal Fractures

Intraarticu lar ca lcanea l fractures h ave frustrated orthopaedic su rgeon s' attempts to fi nd rel iable me th ods of treatment. Some auth ors h ave recommende d passive acceptance of the fact that results a re rotten or even disastrou s (2 74).
O f the ma ny problems with treati ng th e co mmi nuted fracture, the most cha llenging may be to identify w hat deformities must be corrected to achieve a satisfa ctory function al ou tcome. P.1 87 In the era of pla in ra diogra phic a ssessment, a main obje ctive ha d been to restore Bo h ler's angle to n ormal . As C T ha s provide d us with bette r three-dimen sional assessment of the fra ctu re, oth er i nvestigators have demo nstrated the importa nce of restoring the posterior articular facet in o rder to a chieve a s uccessf ul outco me (27 5,2 76,2 77).
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FIGURE 5 -46 A. Th e me th od of reduci ng C olle s fra ctu re o r an y fractures is to re verse the o ri ginal mechan ism of inju ry. Wi th a deq uate ane sth esia an as sista nt h olds th e el bow and provi des cou ntertraction. (1) The surgeo n applies tra ctio n with one ha nd and thum b to th e distal fragme nt. (2 ) Th e forea rm is supi nated and held wit h the su rgeon 's oppo site h and. ( 3) The fra ctu re is th en dis impacted to all ow d orsal angu latio n w hile supina ti on is ma intain ed. B. (1) Th e redu ctio n is then h eld by pron ating the f o re arm an d wris t. ( 2 ) The surgeon's left hand rem ain s station ary while pronation is accomplished by th e righ t ha nd. (3 ) Th e w ri st is directed uln arward to correct radial deviation as well as dorsal a ngula tion o f th e di stal fra gments. (Modified from Connolly J. Fra ctur es and dis loca ti ons. Clo se d man agemen t. Phi ladelph ia: W B Saunders, 1995 , with permission .)
F actors other than art icula r surface co ngruity also may be important inf luen ce s on the results. Sh orteni ng of the heel wea kens th e ga str o cn emius power, leadin g to a calcane us ga it after the fracture heal s (278 , 279). Widen ing and dec reas ed height of the he el wi ll often prod uce la ter al i mp ingemen t on the sural nerve an d per o nea l tendo ns, ca using per sisten t pai n pa rticu larly w ith flexio n and extensio n of the an kle. An impact th at is sufficient to cru sh t he calc an eus will a lso p ro duc e ext ensive dam age to the importan t hee l pa d. Pa in sympto ms can per sist if t he bo ne fragmen ts remain protrudi ng in to th e h eel pad. Swe lling of the wh ole fo ot and limb also contribu te s to pe rma nent s ti ffening, particula rly if the limb is immo bilized i n a cast for a prolo nged period of time w ithou t function al stim u latio n (93 ).
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FIGURE 5 -47 A. Because of the tende ncy for sw elling in this a rea, th e preferred in itial immo biliz atio n o f a Colles f racture is with a su gar-to ng splint. T h e positi on of th e wrist i s main tained by an assista nt u si ng stea dy trac tion o n th e el bow and ha nd ( 1 ). Cast padding is appli ed fr om th e me ta carpal heads to above the elbow (2 ). A felt pad is a pplied to th e lower surface of the proximal fragment (3). A sugar- to ng p laster splint is wrappe d aro und the elbo w an d forea rm an d he ld usin g a circumfe re ntial gauze ban dage. It sh ou ld exten d from th e do rs al surface of the MP joints to the volar surfa ce of the fracture site to maintain the dista l fragments in vo lar angula tion ( 4). B . The sugar-tong splint ca n usually be ch ange d to a short-arm ca st as the swellin g subs ides 1 to 2 we eks af ter the o riginal inj ury. The cas t sho uld be molded firmly on the dorsal surf ace o f the han d and wrist ( 1) an d sho uld maintai n th e wrist i n a mo der ate amount of flexion (2). Extremes of flexion should be a voide d since this can produce a med ian ne uropa thy o r impa ir function o f the intrinsic mu scle s of th e h and. (Mo difie d f rom C on nol ly J. Fra ctu res an d dislocation s. Closed ma nagemen t. Philadelph ia: W B Sa unders, 1 995, with permission .)
P.1 88 Th e general obj ectives of trea tme nt should include not only restoration of the posterior fa cet a rt iculatio n or Bo mo tion . Th ese goals ma y be achi eved by ope ra tive i nterventio n, bu t a nu mbe r of com parative st udies of o per ative ver sus n on opera tive tr eatmen t ha ve sho wn no signi fican t bene fit from surgery unless n ormal an atomy can be re stored (91,278 , 2 80 ,2 81 ). Unfo rtu nately, opera tiv e treatment with wide so ft tissu e dis section risks wo un d slo ugh, inf ectio n, and even am pu ta tion (28 2, 283 ). Buckley and To ugh (92) point out that surgery sh ou ld n ot be recommended to pa tients when the literature su gges ts it migh t result in o nly m argina lly better outcom es a nd freque nt compl ica tion s. Generall y o lder se dent ary patients and t hose wit h no ndis plac ed or with mi nimally dis plac ed fractur es may be treate d successfu lly with nonsurgical man agemen t. Traits which the y feel are stron gly predi ctive of sa ti sfaction with surgery include an age yo unge r than 4 0 years, sim ple fractur e pattern, and accurat e re duc ti on. A reasonable compromise between pa ssiv e acceptan ce of deformity with out reduction a nd th e co mp licatio n-prone ope n redu cti on is m a nua l reductio n of the intraa rticu lar fragmen ts using l igamentotaxis a s described by Omo to e t al (95). Li gaments important for calcan eal fra ctu re stability i nclude t he later al and medial talo calc ane al and interosseu s ligamen ts. Es pec iall y impo rtant are t he tibi ocalcan eal fibers of the delt o id, wh ich a tta ch to the sus tent acu lum ta li a nd th e calc a neo fibul ar l igam ent, whic h attac hes to th e tu ber osit y fragmen t. These tw o ligaments sh ou ld be int act if manu al re ducti on by l igamentotaxis is to be successfu l (Fi g. 5-4 8 a nd 5-49) (284). hler's a ngle but a lso corr ecti on of t h e height, le ngth, and width of the hee l. In a ddition , the treatment sh ou ld a void immobili za tion of th e f oo t a nd e ncou ra ge a ctiv e f unctio nal
Omoto Technique of Reduction

R educ tion o f the acute ca lcanea l frac tur e is car ried out wit h the pa tient prone an d under a deq uate spin al or general an esthes ia. Th e kn ee i s fle xed 90 deg rees to rela x the gas trocsol eus mu scle. An a ssi stant holds the leg in this position wh ile th e operating surgeon stan ds at the patient's feet (F ig. 5 -49). Th e surge on t hen mol ds t he medial and latera l sides of the calcan eus wi th bo th pa lms wh ile cro ssin g the fingers o f both ha nds a roun d the he el. I n this wa y the calcan eal tuberosit y can be squ eezed upward toward the sole. Simultan eou sly, strong tra ction is a pplied to lift the thigh off the ta ble w hile the assi stant exerts counter-force. The he el is then rotated into a varu s or valgu s position d ependin g on w hether the inju ry ha d displac ed the tubero sity fragm e nt in to varus o r va lgus . Tractio n a nd heel suppo rt are co ntin ued while t he tu ber osit y fragm en t is ma nipu lated. Durin g the m ani pulat io n so me crepit a tio n m ay be felt. R oen tge nogra ms are then obta ined to co nfirm the adeq u acy of the re duc ti on. A compression dressing is the n a pplied along w ith ic e to the foot to dim in ish swe lling. Active range o f mo tion o f the foot a nd ankle is e mp hasized on an h ourly bas is w hile the foot rem a ins e levated. Su bs equen tly, the patient may walk wit h cru tche s witho ut bear ing weigh t on the f ra ctu red side. By 2 mo nths afte r the reduc tion t he patien t is allo wed t o s lo wly in cre ase w eightbearin g o n th e in jured fo ot. By 3 to 4 months the patient sh ou ld be able to walk without e xternal support.
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FIGURE 5 -48 T he later al fibu local ca neal liga me nts as well as the t alo calc an eal ligamen ts are impo rta nt in suppo rt ing th e ca lcaneu s fra ctu re . If the me dial and lateral calcan eal ligamen ts are torn , the entire tuberosity fragme nt ma y displace produ cing essen ti ally a fracture-dislocation of the calcan eus. Closed reduc tion by the Omoto techni que dep ends on ligame ntotaxis and require s intact ligament attachmen ts to be su ccessfu l.
Closed Reduction of Tibial Fractures

Biomechanics of Injury
As dis cu sse d with fra ctu re s in the upper limb, the bio mechani cs of in jury of the tibia inc lude direct a nd indirect mechanisms. The c on sistent pattern of a tibia l fracture su sta ined by an in direct torsional me ch anism failure is a fra cture lin e thro ugh the isth mal se ctio n of the tibia ( 252). Here the b one is w eakest a nd here is the area m ost ofte n su bjec ted to t o rsio na l loading. The pattern of failure is ver y co nsistent. Th e proximal fragment displaces medially an d anteriorly relative to th e distal f ra gment. An impo rt ant co nsiderat io n in re duc ing tibial sh aft fra ctu re s is wh ether or not the fibul a is also fractured (2 85 , 28 6). When in ta ct, the fibula, to so me extent, supports th e tibia l fracture but also ma y tend to cause a certa in amou nt of intern al rotation al deformity of a d ista l fractu re. W hen ma nagin g fr actur es o f the dis ta l tibia by casts or fractur e brace te ch nique o r even by closed naili ng, o ne s ho uld pay specia l a tten tion to the r otatio nal align ment of the fractur e ( 28 7, 2 88 ). One mus t e spe ci ally avoid an in te rn al r otatio nal displacemen t of th e a nkle mort ise, wh ich ca n res u lt in varu s p osition ing of the foo t. This po sit ions the foot in a turned in rela tionsh ip to the flo o r, which ca nno t be ove rco me by subtala r motio n. As a consequ ence th e pa tient i s for ced to bea r weigh t on th e l ateral aspec t of the foo t pro duc ing per mane nt P.1 89 d isco mfort in the fo ot and ankle (Fig. 5-2). Th is problem can be anticipate d and prevented by i mmobilizin g the fra ctu re with the foot and an kle in sligh t externa l rota tion . This sh ifts the floor re acti on forc e la terally, so tha t weigh tbearing produ ce s a valgu s rather than a varus momen t at th e fracture si te .
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FIGURE 5 -49 A. Reduc tio n of the acute calcane al fractur e by the Omo to te ch nique is done wit h the patien t un der ade quate ane sth esia. The kne e is flexe d 9 0 de grees an d the assistant ho lds the leg in th is po si tio n. The operatin g surgeo n sta nds a t the patient's feet moldin g the media l an d la te ra l sides of the calc an eus with th e pa lms of both han ds. S imultan eou sly, st rong tract ion is a pplied to lift the th igh off the tabl e. B. With trac tion appl ied to t he calcan eal fractur e, the heel is rotated into varu s or valgus depending on the origin al tu berosity di splacement. Th e tuberosity fra gment is thereby move d closer to th e su stentaculum fragment a nd out of varu s or valg us po si tio n. A compressio n dre ssin g is th en applied an d the foot is ele vated to dec rea se the swellin g. Active mo tion o f the foot and ankle are begun with in the first or sec ond day. (Mo dif ied from C on nol ly J. F rac tur es a nd di slo catio ns. Cl osed manage ment. P hilade lphia: WB Saun der s, 1995, with perm iss ion.)
Techniques of Closed Reduction and Cast Application for Fractures of the Tibia
In applyi ng a c ast to a fractured tibia , it is importa nt that both the patien t an d the person a pplying th e cast be co mfo rta ble. The patien t sho uld be sitting or lying supine o n a s table cast table an d n ot leaning forward from a wheelchair or some other similar mobile support (Fig. 5-50). One of the many re asons that th is is very importa nt i s that it is mu ch h arder to a pply a cast on a moving target. Also, mo st peo ple have neve r ha d a c ast a pplied be fore , an d a fe w u nexpectedly pas s o ut from the e xperience. Th e initial ca st should be appl ied a s soo n as po ssi ble a fter th e injury. A po sterio r splin t provide s i nadequ ate imm obiliza tio n of th e a cu te f ractu re and does lit tle t o relieve t he patien t's disco mfort. If mo st patie nts ar e given an ade quate explan ation a nd th e redu ctio n is do ne gent ly, th e cast ca n b e a pplied without anest hetic a nd with min imal narco tics (2 89, 29 0). As the patient si ts on the edg e of a n o rt hopa edic tabl e with the legs hangi ng do wn, most sh ortenin g ca n be corrected by the use of gra vity and gen tle traction on the dista l fragment and foot (28). Ma lrotation ca n be co rrected by co mparing the tors ion o f th e fractured leg wi th the un fractured leg (Fig. 5-50).
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FIGURE 5 -50 Ca st applicatio n fo r a fractur ed tibia is do ne wit h th e pa tient sittin g on a f rac tur e table. The legs h ang over the ta ble to a llow f ra ctur e rea lignment with gravit y. The c orrect rota ti on is estimated by com paring the fractured leg with th e opposite un fractured leg. (Modified from Connolly J. Fra ctur es and dis loca ti ons. Clo se d man agemen t. Phi ladelph ia: W B Saunders, 1995 , with permission .)
Two to three layers of cast paddin g are first applied from the toes to above the knee . Subsequently, a 4 -inc h roll of pla ster P.1 90 is applied to the foot and ankle with care taken to contour the arch of the foot. A 6-inch roll of p laster is then rolled from the foot up to the k nee. The fracture is aligned by molding the plaster to co rrect any varu s or valgu s tenden cy. When the lower leg plaster has ha rdened, the knee is exten ded fully an d t he cas t is applied abo ve th e kn ee (F ig. 5 -51). P ostreduction x -rays are th en taken to evaluate fracture alignme nt. It is more important to restore th e axis o f motio n o f the knee to a norma l rela tio nshi p with the ankl e tha n i t is to a ch ieve per fect a lignment of th e fracture fragments. How ever, good cortical contact i s important to preven t d ispla cem ent of the fra ctu re fragments i n th e cas t ( F igs. 5- 5 2 a nd 5-53 ). X-ray s s hou ld be taken o f th e pa ti ent in t he cas t sh owin g the align ment of the knee an d ankle on the sam e ca ssette (Fig. 5-54). This may require that the cassette be placed diagonally for tall patients so that both joints can be v isu alized on the sam e film. Sho rten ing P.1 91 P.1 92 o f 1.5 cm or l ess is qu ite ac ceptable pro vided th at the kne e an d a nkle axes are ret u rned to n ormal a lignm en t. Anterio r angulatio n of the proxi mal fr agmen t sho uld be av oided since it can lead to s kin slough from ca st pressu re (Fig. 5-54B). Pos terior angu lation of the dista l fragment s hou ld a lso be a voide d by allo wing the foot to ma intain a slight equinu s po si tio n in the ca st (Fig. 5-54C ). After the re duc ti on, the patient is usu ally adm itted to the ho spit al to e nsure th at the leg is el evat ed using an o verhe ad su spen sion . The patient is en coura ged to act ively exerc ise th e to es.
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FIGURE 5 -51 A. Cast padding is a pplied to the f ra ctu red limb ove r a sto ckinette, and the leg is padde d up to appro ximately 6 to 8 in ch es above the knee. B. Plaster is applied ove r the cast paddin g and mo lded firmly aro und the foot a nd ankle usin g the p alm of the ha nd and no t the fingers. C. The cast is then extended over the fracture site up to the knee and the fracture is reduced as th e pla ste r sets by molding firmly a round the calf muscles and along th e fracture itself. D. T he ca st is the n e xte nded above the knee wit h t he knee close to full exten sion . The patien t may be up pa rt ially weightbea ri ng w ith crut ches when the plas ter has harden ed. T he leg sho uld be el evated co ntinu ou sl y wh en th e pa ti ent is no t ambu lating. (Mo difie d fr om Conno lly J. Fra ctu res an d dislocation s. Closed ma nagemen t. Philadelph ia: W B Sa unders, 1 995, with permission .)
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FIGURE 5 -52 A,B . Anteroposterior (AP ) x-ra y of a typica l tibia a nd fibula fracture su sta ined in a chara cteristic indirect torsional injury to the leg. Th e pa tient's fractures resulted f rom th e foot and ankle being fixed while the uppe r body twisted a bou t the t ibia, resu lting in the classic spiral obliqu e fracture from the distal me dial cortex up to the superior lateral co rtex of the tibia. The ch aracteristic displacement of th e proximal fra gment a nteromedially was a ccepted wh en th e pa ti ent w as tr eated in the ca st as i llustr ated on these x- ray s. C,D. With early weigh tbearing in a fractur e c ast or brac e th e frac tur e heal s with periostea l an d en dosteal c allu s as illus tr ated on these A P and lateral x-ra ys at 12 wee ks. S light sh orteni ng wa s accept ed and felt to be helpf ul to achieve early hea ling of the fra cture a nd e xcellent functiona l reco very of the an kle a nd kn ee. No te th at the x-rays e valua ti ng a lignm en t of th e fracture were tak en to inclu de th e kn ee a nd ankle on the o ne ca sse tte to be certain tha t bo th pro ximal dista l j oin ts were properly aligned.
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Th re e-point weightbearing using cru tch es is sta rted the day after the ca st is a pplied (1 2). The patien t sh ould be advised there will be some discomfort a nd possibly some fracture motion felt in th e first few weeks. Th e impo rt ance of ele vating the leg wh en no t walki ng sh ould be emphas ized to avo id e xcessive swellin g a nd tigh te ning in the ca st. How ever, an y co mplaints of pain ful tigh tn ess un der the ca st warrant splitting th e cast and c ast paddi ng to a lleviate the symptoms an d prevent an y problems su ch as compartment syndrome.
FIGURE 5 -53 A. A lth ough slig ht displaceme nt of a ti bial fracture pers istin g after clo sed reduc tio n ma y be ac cept ed, one s ho uld not accept less th an 50 % apposit io n o f the bon e fra gments. The m alredu ction illustrated by thi s spiral obliqu e distal tibial fra ctu re is un accept able since i t lacks e ven minimal bon y co ntac t. I t only dis plac ed furt her when the patien t began w eightbearin g in t he heavily padded ca st. B. X -ray at 3 w eeks sho ws dis plac emen t o f t he tibi a and fibul a and v algus til t of th e a nkle. Th e frac tur e was t h en trea te d by open reduc tio n and interna l fixatio n to co rre ct the sh ortenin g a nd a ngula tion . Fra ctu re s that are tr eated by clo se d func tion al methods deman d ade quate reduc tion ju st as do fractur es treated by open reduction a nd i nternal fi xation .
By 2 to 3 weeks the long leg cast may be changed to a short leg patella tendonbearing (PTB) cast or a fracture brace (28, 63). While the long leg cast may continue to be used, the major advantage of th e short leg PTB ca st or a fracture brace i s that the patient is usually able to return to work or scho ol m o re rapidly an d ha ve a s en se o f being able to functi on more no rm ally (Fig. 5 -55) . Th e ma jority of low-energy tibial fractures ca n be treated by closed reducti on and a fu nction al w eightbearing cast or fracture brace (285). U sually, these fractures are su pported by the intact i nteross eo us membran e (2 33) as we ll as by th e surro undin g calf mu scle s. In a ddit ion, if the fibu la is n ot fractured, it may also h ave a stabil izing affect. Severe displacement of th e tibia l fracture ca n o ccur wh en there is comple te dis ruptio n o f the intero sseo us memb rane and surr ou nding mus cle. Th is ca uses signi fican t P.1 93 sh ortenin g and instability of the fracture an d requ ire s either externa l fixatio n o r in te rnal stabilizatio n o f the tibia (17,6 3,28 8,29 1,29 2).
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FIGURE 5 -54 A. Postreduction x-ra ys should be take n w ith the patient in the cast to show ali gnm ent of the kne e a nd a nkle as w ell a s the fra ctur e . This ma y requ ire pla ci ng th e x -ray cas sette dia gon ally to vi su alize the proximal an d distal joints . B. Anterior angu latio n o f the proxi mal f ragmen t of th e tibia can cau se slou ghing o f the skin if it produc es pres su re n ec rosis un der the cas t ( left). This can be corrected by allowin g slight recurvatum of the f ractu re a s the cast is being applie d (right ). C. P osterio r an gulat io n of the dis tal ti bial fragm en t can o ccur wit h attempts to dorsiflex the ankle durin g cast application (left). Allowi ng sligh t equ inus to po sition the foot will partially correct this tendency (ri ght ). (Mod ified from Connolly J. Fractur es and disloca tions. Close d man agemen t. Ph iladelph ia: W B Sau nders, 1 995, w ith perm iss io n.)
Closed Reduction of Proximal Tibial Plateau FracturesInfluence of the Fibula on the Mechanics of Proximal Tibial Fractures
The usual proximal tibial fracture is the result of a direct blow to the lateral aspect of the leg or k nee, th e so -ca lled ca r bumper inju ry (29 3). T his usua lly pr o duc es a latera l pla te au fractur e that may or ma y not be asso ciated with a fibular fracture. If th e fibula is intact, the inj ury can be consi dered st abl e. The fib ula s upports th e late ral pl ateau an d preven ts it f rom dis placing signif ica ntly (2 94). O ne sh ould be alert to th e dif fere nce be tw een the cla ssic lateral t ibial platea u fracture su stained with th e kn ee i n e xtension an d the in jury su stained with th e kn ee in a flexed posit io n. Th e latter inj ury p ro duc es a mu ch grea te r amo unt of kn ee i nstabilit y (F ig. 5 -56) . The tende ncy is for this fractur e to crea te a d isplac ed posterome dial fragm en t tha t can allo w th e medi al P.1 94 femo ra l co ndyle to subluxa te in to th e defect (24 3). This causes co nsiderabl e insta bilit y of the knee a nd a tendency for the deformity to recur even with attempted i nternal fi xation . These different me ch anisms of inj ury mu st be considered in order to ch oose treatment based on reversing the me ch anism of in jury.
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FIGURE 5 -55 By 2 to 3 week s the ca st may be repl ac ed by a frac ture brac e. Th is is a pplied over a stockine tte and con si sts of a prefa bricated plasti c shell attached with Velcro straps. A he el cup an d ankle join t are attache d to allo w ankle dors if lexio n. The patie nt sho uld wear a tenn is s ho e a nd actively u se the kne e a nd a nkle as th e frac tur e h eals. (Mo difie d f ro m C on nol ly J. F rac tur es an d dislo cation s. Clo sed ma nageme nt. P hilade lphia: WB Sa unde rs, 1995, with permission .)
W hile man y la te ral tibia l pla teau fra ctu re s can be trea ted symptoma ti ca lly a s previo usly de scribed a bove , the majority require some type of redu ction with or w ith ou t internal fixation. In dica tion s for e ither operative or nonope rative treatme nt a re clinical as well as radiograph ic. The most e xte nsive l ong-term studi es o n th e subj ect ha ve bee n ca rrie d o ut by Rasmus sen (29 3, 2 96 ) an d by Lans inge r a nd associates (2 97 ), who demonstrated th at the o utcome of the se f ra ctu res can be predicte d by str essing the knee in ful l ext en si on. Knee s with a lateral t ibial plateau f rac tur e th at are s table in t he fully exten ded po siti on gene ra lly h eal well without th e need f or exact a nato mic reductio n. For this re ason it is often no t ess ential in t hese ca ses to achie ve perfect joint ana tomy by open su rgical p rocedures (25).
Technique of Closed Reduction

W ith the patient under genera l anesthesia on a fra ctu re table , traction is ma intain ed w hile an a ssi stan t appl ies dir ect ma nua l man ipula ti on to correct an y ten denc y to va lgus a ngula tion (24 3). This co mb ina tio n of t rac tio n a nd varus ma nipul ation ele vates the plat ea u fractur e using the ligamen to us p ull of soft tissue attachments ( Figs. 5-57 and 5-58) . The effect of this ma nipulation can be assesse d i mme diately by image intensifie d fluo ro scopy. Widening of the condyles can be reduced by direct ma nua l compre ssion along w ith percuta neous screw insertion . Arthroscopic a ssessmen t of the a rticul ar surface has been recommende d (298), but can be di fficu lt, a nd additio nal swelling of th e joint can be pro duc ed by the art hro sco pic p ro cedur e itse lf. In o ur o pini on, art hrosco py o f the acute f rac tur e is mo re likel y to complica te tha n it is to aid reduc tio n. After alignmen t is determined to be satisfa cto ry by x-ra y, a cast brace can be a pplied with th e p atient still on the f ractu re tab le. Hinges are incorporated to allow 40 to 50 degrees of knee mo ti on
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(F ig. 5 -59) . The patien t subs equ ently is allo wed to bear pa rti al w eight in th e cast brace and e ncou ra ged to a ctive ly exe rcis e t he knee. Th e ca st brace i s main ta ined fo r 6 to 8 weeks. Ma ny of th ese fractur es wil l heal wit hin 6 weeks, a fter whic h immobil ization in the cast brace may be d isco ntinu ed. Oc cas io nally , if the fra ctu re is n ot reduced by man ipulatio n, open redu ctio n and p ercu ta neo us fixatio n with ca nnu lated scr ews ca n be u se d (25 , 299). Thi s is pa rticu larly l ikely i f th e frac tur e has invo lved th e poste ro medial aspec t of the tibial condyl e pro duc ing a su bluxatio n of t he k nee joi nt in the fl exed po sit ion (Fig. 5-60 ). O n long-t erm f ol low-up (25) of patie nts whose f ractures h ave been reduced by th ese techn iques , re su lts ha ve bee n co nsidered sa tisfactory particula rly whe n ba sed o n functi ona l outc ome. R adio graphic ch ange s of sc lero si s an d wha t migh t be interpreted a s osteo art hritis ma y be seen afte r th ese in juries; h owe ver , we have no t f ou nd a co rre lation bet we en th e rad iolo gic findings and the g eneral clinic al result. Th is con tra sts wit h other jo ints suc h as th e ankle or the hip w here ra diograph ic c ha nges o f po sttrau ma tic arthritis usuall y correla te c lo se ly wit h clinica l an d f unctio nal outcome . The knee, and particula rly the latera l plate au, is protected to some extent by the lateral me nisc us, wh ich ma intain s a signif ica nt w eightbearin g f unctio n d espi te fra ctu res inv olvin g the a rticu lar surface of the la te ra l plateau.
Femoral Fractures Reduced Nonoperatively by Skeletal Traction and Cast-Bracing

Th e most widely accepted and usual ly reliable me th od of managin g femoral shaft fractures is with clo sed redu ctio n and closed intram edu llary naili ng (3 00). Th is can us ua lly be acco mp lished as soo n as th e pa ti ent's overall sta tu s al lows, preferably within the f irst 24 to 48 hours after inju ry. O cca sio na lly f emora l f ractures requ ire a lte rn ate non opera ti ve meth ods ( 301) . Typica l in dica tions fo r n on operative treatment include co mmi nuted fractures of the distal third of the femur, op en femo ral sh aft fractur es, inf ecte d fra ctu res, an d tho se in wh ich internal fix ation m ay be te nuo us a nd su pplemental externa l supp ort is required (3 02). In a dditi on, closed intramedu llary n ailin g techn ique ma y n ot b e av ailable in some comm u nities o r co untries be ca use th e e quipment is in ordina tely e xpensive. Unde r these cir cu msta nces the nonoperative te ch niqu e can pro duce ex cel lent re su lts (303). P.1 95 P.1 96
Technique of Inserting a Pin for Distal Femoral Skeletal Traction

Th e traction pin in serte d in the distal femur gives be tter control of the fracture than a pin in the p roximal tibia. Th is is generall y the prefe rre d loca tion f or most femoral shaft fractures except very d ista l ones. T he pin is i nser ted f rom th e me dial side un der lo cal anest he tic, taking care to a void the n eurovascular stru ctu re s in the posteromedial a spect of the kn ee. A han d drill is u se d to insert a 3 mm St einman n pin. Stell ate in cisi ons arou nd th e pi n a t the entr an ce an d exi t sites preven t pinch ing o f the skin (Fig. 5-6 1). P addin g is pl aced a roun d the pin, a tra ction bow is atta ch ed, a nd th e li mb is su spe nded in balan ce d trac tion in a H arris o r sim ila r splint using a Pearso n a ttachm ent to allo w kn ee flexio n (Fig. 5 -29).
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FIGURE 5 -56 A. Ti bial plateau fra ctures s ustain ed in flexio n are gen erally more unstabl e tha n tho se sustain ed w ith the kne e in exten sion. The flexio n inj ury f requen tl y cau se s the medial fem oral con dyle t o im pa ct on the po stero medial condy le o f the ti bia, res u lti ng in a tende nc y f or posterior s ubluxation. B . T he fracture produ ced with the knee in flexion tends to result in a po stero medial instabili ty an d persis tent su bluxatio n of the femoral con dyle posteriorly. Th is require s reduction by realign ing th e di spla ced po ste ro media l fra gment of the tibial condyle wi th the knee in extensio n, th ereb y re versin g th e mecha nism o f inj ury. (Modi fied fro m C onnolly J. Fra ctu res an d dislocation s. Closed ma nagemen t. Philadelph ia: W B Sa unders, 1 995, with permission .)
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FIGURE 5 -57 A. Th e tech nique o f clos ed redu cti on of a tibia l pla te au frac ture sus taine d in flexion is to reverse the mechanism of injury. Traction is applied to the extended knee using a fra ctu re tabl e with the patien t un der ade quate ane sth etic. A va ru s o r valgu s lo ad ca n be appl ied to correct the deforming tende ncy of the knee. B. In this ca se the lon git udina l tractio n on the exten ded kn ee e levates th e lateral pl ateau fra gment u sing ligamento taxis. (M odi fied fro m Conn olly J. Fra ctu re s an d dislo ca tion s. Clo sed man agemen t. Ph iladelph ia: W B Sau nders, 1 995, with perm iss ion.)
FIGURE 5 -58 A. Th is co mmi nuted fracture of th e media l tibia l pla teau was su stained by a mo to rcycl ist with th e kn ee in flexion. Th e ten dency for po stero medial displacem en t is ev ident. B. The re duction o f th e po steromedia l displa ceme nt wa s accompl ish ed u sing l ongi tu dinal traction o n th e fracture ta ble w ith the kn ee in exten sion. This r eve rsed the origin al mechani sm o f th e i njury, whic h was flexi on ove rl oad. C. The reduced fractu re wa s fu rth er stabili ze d with
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percutan eou s screws an d supported wi th a cast bra ce. D. T he x- rays 4 years la ter sho w satisfa ctory maintena nce of a norma l j oint space, compared to the opposite knee.
Fo r fra ctu re s in the proximal femur, 9 0 90 tra ction is preferred. Afte r the pin is inse rted in the d ista l f em ur, th e h ip is flexed 90 deg re es an d abdu cte d to alig n the dis tal fra gme nt wi th the proxi mal fragment. The knee is kept flexed at 90 degrees and the leg is supported in a cast (Fig. 5-30). P.1 97 Ini tially 15 to 20 pounds of traction a re appli ed to distract the f ra ctu re sligh tly. If necessary, this w eight ca n b e in crea sed to 30 po unds. The fo ot of the bed sh ou ld be eleva te d 30 de gre es to provide co untert rac tio n a gains t th e pu ll of the tr acti on appa ra tus .
FIGURE 5 -59 A cast bra ce is applied to su pport th e tibia l plateau fra ctu re after close d reduction or w ith internal fixation with the patient still on th e fracture ta ble (1 ). The hinges of the cast brace are incorpo rat ed so a s to apply a valgus loa d on th e kn ee to u nlo ad th e media l tibial c ondyle (2 ). (Mo difie d from Conno lly J. F rac tur es a nd disl ocatio ns. C losed mana gement. Ph iladel phia: W B Sa unders, 1995, with pe rmi ssio n.)
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FIGURE 5 -60 A. This co mmi nuted bicondy lar fracture of the tibia with extension into th e tibia l metaph ysis was reduced by longitudin al tra ctio n applied to the knee in extensio n. Bec a use of the comminution , percutaneou s scre w fixation w as u se d to hold the redu ction, permitting a mini ma lly i nvasive tec hniqu e for dealin g with this unstable in jury. B . Reduction after lo ngitudin al tra ctio n to th e e xtended knee and percut an eou s screw fixation wa s suppleme nted wit h cast- bra ce suppo rt. This tech nique avo ids the ne ce ssity of wide dis section of th e bic on dylar fractur e, whic h c arr ies the risk of deva scul arizing co mm inu ted bo ne fragm e nts an d probably increases the risk of infection .
Technique of Closed Reduction and Cast-Brace Application

Th e cast- brace tech nique was introdu ced by Mooney and co-wo rke rs (304 , 305). It per mi ts a frac tur e to be reduced by clo sed mea ns a nd th en held in align ment wh ile th e pa tient becom es a mbulato ry a nd i s able to fle x and exten d the kne e. This met hod is felt to m a ximize th e natural hea ling processes sin ce extern al ca llus forms quite quickly, pa rticu larly i n th e first 6 weeks after the injury. It mi nimizes di su se atr o phy of jo ints a nd mus cles, whi ch ha s f ollo wed other no no per ative me th ods. Th e me th od does require skill a s well as ca refu l follow-up to a void excess ive angul ation o r shortening of th e fracture site. Howe ver, for certai n fractures, particularly comminuted distal femo ral fractures, the me th od in our ha nds h as some ti mes prove n more effective mecha nically than the less stabl e i ntr amedull ary n ailing by re tro grade P.1 98 o r o ther te ch nique s ( 302 , 3 04 ). It is also u se ful for e lder ly o ste opo rotic pa ti ents wh o su stain a su pracondy lar distal fe moral fra ctu re fro m a fall. Th e pa tient ca n u sually adj ust to a cast brace and a mb ulate for fun ctio nal purpo ses durin g the 8 to 10 wee ks required for h ealin g.
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FIGURE 5 -61 A. Te ch niqu e o f insert ing s keletal pins for fe mo ral trac ti on. A skeleta l traction pin is in serte d in the dis tal femu r fro m the media l to the later al side. Lo cal anesthe ti c is infiltrated down to the periosteum , and care is take n to avoid the neurovascular stru ctu re s in the post ero medial aspect of the knee. A hand d ril l is used to in se rt the 3-m m Stein ma nn pin, an d care is take n to a void pinc hin g o f t he ski n, wh ich ca n be pai nful. B . The pin is padded and a traction bow is attached to apply 1 5 to 20 lbs to the fractu re in a Harris splint. (Modified from Conn olly J. Fra ctu re s an d dislo ca tion s. Clo sed man agemen t. Ph iladelph ia: W B Sau nders, 1 995, with perm iss ion.)
In m ost instanc es a ca st brace ca n be appli ed with t he patien t in bed and lightly sedat ed. T h e fem ora l sh aft fractur e s ho uld have been ali gned and pulled ou t to len gth by the tra ctio n techniqu e prio r to the cast-brace application (243). The duration of skeletal traction may vary from a few days to 3 or 4 w eeks depe nding on the ini tia l stabil ity of the frac ture (301, 30 4) (F ig. 5- 6 2). Fractures in th e distal third of the femoral shaft tha t are relatively un displ aced a t the time of p re sentation can be mana ged by early c ast-bra ce applica tion in the first few days a fter inju ry. Other, mo re u nstable or open femora l shaft fractures re quire l onge r periods for th e initi al stability of th e fracture to develop. W ith the patient in bed, an a ssistan t main ta ins stea dy trac tion o n th e di stal femoral pin. A Span dex sto cki nette is rolle d over the leg and across th e pin . The assistant co ntinu es to suppo rt the leg while a 6 -i nch role of plaster is appl ied snu gly to the thigh . Fra ctu res in the distal th ird are best reduce d w ith th e kn ee in exten sion and the leg in external rotation to correct varu s deformity (F ig. 5-6 3). The l ower leg portion is applied next, followe d by th e kn ee hinges, which s hould allow kne e mo tion o f at l east 3 0 to 4 0 degr ees to ma intain the quadriceps and ha mstring function . Havi ng so me kn ee mo tion a lso elimina tes torsio n on t he fractur e site tha t wo uld be pro duc ed by a lo ng le g cas t w ith the kn ee in e xtension . Th e distal fe moral traction pin is le ft in pla ce belo w th e end of the thigh c ast un til x-rays have d emonstrat ed satisfacto ry reductio n i n th e cast brace. The pin actuall y may be left in for several days mo re w hile the patient bec omes amb ula to ry to pro te ct agai nst dela yed displa ce ment. It is importa nt in applying the cast bra ce to mold over the femoral condyles to provide a dequate su pport to the distal femoral fracture; 1 to 2 cm of shorte ning of the fracture ma y be accepted, and i n fact, is encou raged in order to clo se do wn the fractur e gap. Th e clo sed metho d of treating these fractur es has an adva ntage of n ot di stur bin g the frac tu re mili eu, a nd th e e arly mo bilizatio n of the patien t with partial weigh tbearing promo tes an ab undan t extern al ca llus. He aling becomes fa irly stable by a bou t 6 weeks, at which time the cast brace may be cha nged. Gen erally, 12 to 16 weeks are required for the f ra ctu re to he al su fficiently to remove th e ca st brace. During this recovery period the patient shou ld be encourage d to work vigorously to maintai n
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q uadriceps a nd hams tr ing functi on and ran ge of motio n o f the knee fro m full ext ensio n to at lea st 30 to 4 0 degrees o f fle xion .
Nonoperative Treatment of Acetabular Fractures

In his review of the classic literatu re on acetabula r fractures, Tile (1 26 , 30 6) pointed out the i mportance of di stin guishin g apple s from orange s, that is, dis tinguish ing th e rela tively u ndisplaced a cetabula r fra ctu re produced by low-e nergy i nju ry fro m the gro ssly displaced high-energy acetabular fracture with pelvic disruption. Low-energy injuries produce th e ma jority of ace ta bular fractu re s, p articu larly in th e e lder ly. These usua lly n ondispl aced, o r min imally dis placed st able fractu res can be treate d nonoperatively with very sa tisfying results, provi ded the fra ctu re is recognized and the p atient is main ta ined on a wal ker to preven t displacem en t (307,30 8,30 9). E ven so me displ aced frac tur es ca n be reduc ed by clo sed me ans and tre ated n on operativel y. In his origin al cla ssic study on the su bject, Let o urnel (310) cautio ned abo ut sign ifican t compli ca tions f rom ope n redu ctio n of a ce ta bula r fra ctu re s inclu ding e xte nsive ecto pic bo ne fo rmation , in fection , scia tic nerve inju ry a nd va scu lar i njury whic h o ccu rred in 28 % of patien ts treated operativel y. These stat istics h ave not chan ged signi fican tly in ov er 20 ye ars since opera ti ve tr eatmen t o f ac etabula r frac tur es h as i mp ro ved te ch nically (31 1). T orn etta (31 2) h as po inted ou t that clinic al results a fter su rg ery are better in younger patien ts than in o lder pa tie nts. Older patients are mo re likely to h ave p oor bon e sto ck an d suf fer loss of reductio n when tr eated opera tive ly. Co nsequ ently, ma ny su ch p atients wo uld be bet te r candi dates for to tal joi nt repla ce ment once s ome fractur e hea ling has oc curred ra th er P.1 99 P.2 00 th an unde rgo ing an at temp ted acute open redu ctio n and interna l fixatio n. In additio n, be ca use of the n eed for special reduc tion c lamps , spe ci al tractio n ta bles, ne urolo gic m o nito ri ng a pparat us, and q ualified assista nts many in stitutions are really n ot equipped to properly support this type of surge ry. Th is must be serio usly c o nsidered by an y in dividua l surg eo n making the dec ision wh ether to o perate or transfer th e pa tient to a center specializing in care of these fractu re s or treat the fracture n on opera tive ly ( 31 2) .
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FIGURE 5 -62 A,B . T hese anteroposterior lateral x-rays a re taken of a com minu te d distal third femoral fra ctu re that was tre ated w ith a pproximately 2 weeks of traction foll owed by ca st bracing appli ca ti on. Fractur e hea ling is evide nt on the a nteropo sterior lateral x-ra ys at 14 week s, when the c ast- bra ce wa s remove d. C. Th is gun shot fracture of th e distal fe mur was
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suf ficien tly stable without trac tio n to pe rmit cas t- brace applica ti on wit hin 1 wee k. D. Fracture un ion wa s eviden t whe n th e c as t-brac e w as rem o ved a t 12 w eeks.
FIGURE 5 -63 A. Co mmi nuted fractur es of the dis tal femu r can be adequ ately a ligned by dista l femoral tract ion . Wh en the initial s wellin g subsides , a cas t brace is applied with an assist ant main tainin g trac tion . T he surgeo n applies the cas t, molding o ver the fra ctu re sit e. Th e kn ee is he ld in exten sio n and the leg is slightly ext ernal ly ro ta ted to c orrect a ny te ndency to varus an gulat io n of the fra ctu re. B. The cast is attached by hinges to a knee cast below (1). The distal femoral tra ctio n pin is lef t in place un ti l the stability of the fra ctu re is ascerta ined by x ray on ce t he p atien t has become amb u latory ( 2). If the sta bility of the fracture is in que stion, a pelvic band wit h a hinge o r a pelvic min i-spi ca can be at tac hed to t he ca st to pr ovide hip stability (3). (Modified from Connolly J. Fractur es and dis locat io ns. Closed man agement. Ph iladel phia: W B Sa unders, 1995, with pe rmi ssio n.)
C on sequently, closed no nope ra tive ma nagem e nt o f many acetabu lar f rac tur es i s still a n impo rt ant skil l for th e fr acture su rgeon t o m ain ta in. Clo sed reduct io n ca n be appl ied to man y displa ce d a cetabular fra ctu res including th e centra lly protruded femoral h ead, com mon ly found in osteoporotic p atients. The objective i s to restore join t con gruity wi th ou t necessarily requirin g operative invasion. R owe an d Lo well (3 13), Lowell (31 4), an d ot hers (31 5,3 16,3 17,3 18) hav e descr ibed th e tech nique of ma nipu lative re duction of a cetabula r fractures . The typic ally displ aced a ce ta bular fra ctu re with p ro tr usion o f the femo ral h ead centrally and super io rly sho uld be redu ced a s early as possible if th e closed a tte mp t is to succeed. As soon as the patien t's condi tion is stabilize d sufficiently to allow a dequa te an esthes ia, manipu lation is carried out to disimp a ct the dis placed cen trally pro truding femo ra l h ead (Fig. 5 -64). This requires inserting a tra ction screw directly i nto the gre ater troch anter i n order to provide su ffici ent lateral tra ction to di simpact the femoral head. I f tra ction is applied sim ply to a dista l femora l tractio n pin , redu ctio n is likely to fa il sin ce the force vecto rs need to be d ire cted lateral ly as well as di stal ly. After the trocha nter screw is in se rted using s terile technique , the patient is turned on th e opposite side an d a pillo w o r bo ls ter is placed be tw een the thighs to a ct as a fulcrum . Th e dis lo cated fem ur is a dducted over th e bolster wh ile th e traction screw is pul led late rally to direct the femoral h ead ou t of th e ace ta bulum . Of te n a c ha ra cte ri stic pop will be felt j ust as wit h any othe r successful jo int re duc ti on. The re duc tion is co nsidered accept able if the radiogra phs demo nstr ate th e femo ra l h ead to b e ret urn ed co ngruen tly un der the do me o f t he acetabulu m. Sligh t pers iste nt displa ce ment o f t he i nner acetabu lar wa ll or a nterior or posterior colu mns m ay be accept ed sin ce this usuall y do es no t
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a ffect hip function a fter th e fracture heals. Th e ke y to successful closed reduction is restoration of th e rela tionsh ip of the femo ral head to the weightbea rin g do me of the acet abu lum (3 19, 32 0). P re cise a nato mic redu ctio n of t he art icula r surfaces as emphas ized by advoca te s for o pen reduc tion h as n ot p roven to be e ssential for a satisfactory outcome after successful closed tre atment (Fig. 5-65). H oweve r, post erio r sublu xation o f the fem o ral h ead shou ld n ot b e accepted (321, 322). C aref ul CT a nd other radio graphic evalua tion may be necessary to rule o ut pe rsistent posterio r displac emen t. If n ecessary, stress views may be obtained un der fluoroscopy as described by Torn etta (3 23) to d ete rmi ne th e stabil ity of th e h ip a nd th e poste ri or acetabulu m. Any degree of posterior insta bility d ocumen te d clinica lly or by x-ra y requ ires o pen re duct ion an d inte rn al fixa ti on to resto re po sterior stability and co ngruen cy to the joi nt. O nce an adeq ua te redu ctio n is ach ieved, th e pa tie nt is tra nsferred to a fractur e bed a nd tro chan te ri c tr a ctio n is con ti nued using 20 to 3 0 p oun ds o f weight . In additio n, dista l femora l P.2 01 tr a ctio n is appli ed ag ain using 20 to 30 po un ds. Adequat e con ti nuo us tractio n tech nique mus t be ma intain ed u ntil th e a ceta bula r fra gments begin to co nsolida te (32 4) .
FIGURE 5 -64 As with any oth er disloc ation , closed reduction of acetabu lar fractures sh ou ld be carr ied ou t as soon as possible. With the patient unde r ade quate anesthe sia , a trocha nteric screw is inserted under ste rile techn ique (1). The patient is turned on the opposite side on a pillow. A bolster is placed between the thighs to act as a fulcrum (2). T he dislo ca ted f emur is addu cte d over the bol ster while the traction scre w is pulled laterall y to lever the femoral head o ut of the acetabulu m ( 3 ). O ften t he dis locatio n will re duce w ith a po pping se nsation . If the reduction is successful and con firmed by x-ray, tra ction is a pplied to the trochanteric screw as well as to a tract io n pi n in serte d in t he dis tal femur. This a llows both lateral an d longitudi nal tr action to main tain t he femo ral head unde r the dome o f th e a ce ta bulu m. (Mo dif ied from Conn olly J. Fra ctu re s an d dislo ca tion s. Clo sed man agemen t. Ph iladelph ia: W B Sau nders, 1 995, with perm iss ion.)
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Ma ny su rgeon s are reluctant to use l ateral troc han te ri c traction for fear that it increase s the risk of i nfe ction sh ou ld surgery become necessary. If the initi al a tte mpt at closed re ducti on is u nsuccessful a nd alignme nt of the femo ral head remain s noncon ce ntr ic wit h t he acetabu lar do me, th e tr och anteric p in sh ould be r emoved immediatel y. The patient is the n ma intain ed in dis tal fe moral t ra cti on un til operative reduction ca n be carried ou t. A major objection to closed traction treatment of th ese fractures is that it man dates continu ed tra ction of 6 to 10 we eks in order for the acetabular fragments to heal sufficiently. The hea ling p ro ces s cann ot be rush ed (31 8). W hile s ome traction weigh t may be re moved at 3 to 4 wee ks, re mo ving the trac ti on too ea rly wil l result in loss o f reduction a nd w ill requ ire rea pplic ation o f the traction if an unsatisfactory outcome is to be avoided (Fig. 5-66). The method has numerous a dvanta ges an d do es a void poten ti al co mplication s o f extens ive surgery (32 2,3 25,3 26,3 27 ,3 28 ,329 ). W hen redu ction by closed methods succeeds, th e l ong-term outcome is as good as operative tr ea tme nt. Approx imately 7 5% o f successful clo sed redu cti ons of a ce ta bular fractur es have satisfactory outcome, while 25% to 30% d o poorly. The poor outcomes from closed or open treatment re su lt from th e severity of the impact on the articular s urfa ce as often as from problems of ade quate re ducti on of th e fr agmented acetabu lum (319 ,3 30 ,331 ,332 ,33 4,33 5).
SUMMARY Advantages of Nonoperative Management

Th e term non opera ti ve is misl eading since any closed reduction of a fracture shou ld be con si dered a n operative procedure a nd a pproached with appropriate ca re and pla nni ng. C losed reduction , by n on opera tive mini mally invas ive metho ds , remain s the tre atm ent of cho ice for m any fra ctu re s toda y. Th e objective is to reduce the fracture by ma nipulation and/or traction, a ssess th e reduction clinically a nd radiogra phic ally, and then main tain align ment by a variet y of techn iques includin g cast s, f ra ctu re P.2 02 b ra ce s, external fixators, or, if n ecessa ry, closed intrame dullary nail ing or pe rcu ta neous screw fixatio n.
FIGURE 5 -65 A. X- ra y of th is commi nuted fracture of th e a nterior and posterior acetabu lar
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colu mns sh ows cen tral pro trusion of th e f emo ra l h ead. B. The patien t wa s treated by closed reduction with a troch anteric screw and satisfa ctory repositi onin g of the femoral head under the acetabu lar dome was achieved. Subsequently, traction wa s applied to the trochanteric screw a s well as to th e distal femur for app roxi mately 6 w eeks. C. X-ray of the hip at 2 years shows he aling of th e ace ta bular fractur e an d main tenan ce of a sa tisfactory jo int spa ce wit h exc ellen t, ne ar- n ormal motio n, and function o f the hip j oin t.
C losed reduct io n, wh en d one we ll, can avo id infe ctio n and the problems of techn ica l e rro rs, which , th oug h in frequ ent, a re rea l risks o f open techn iques (34,28 2,2 89,2 90 ,3 22 ,325 ,327 ,32 1). Cl osed n on opera tive man agemen t ha s gene ra lly pro ven les s co stly than h as o perat ive mana gement o f man y fractures, if th e princi ples of functi onal fracture treatme nt a s best described by Sarmiento and others a re foll owed. Empha si s on close d man agement of fractures is con sisten t with the growin g acceptan ce o f no nin vasive or min imally inva si ve methods o f all surgic al t ech niqu es, not ju st fra ctu re fixation . Th erefore, it is essential that the fra cture surgeon understand the mechanics of closed fracture re duc ti on as well as o pen su rgical tech nique s (34, 33 6).
Disadvantages of Nonoperative Management

W ith no nope ra tive tec hn iques , a certain a moun t of mechan ica l, a nalytical, and tac tile ski lls are re quired and m ust be learn ed. Also, t here se ems to be an unfortun ate tren d n oticed on review of closed ma lpractice claims (3 37 ) that complications a fter ca st treatment of certain fra ctu res, p articularly in th e tibia , are m ore likely to lead patien ts to se ek medica l-le gal re co urse th an are more significant compl ica tion s after operative treatment. This may ofte n be based on some arbi tra ry d efin itions of a n accept able re duc tion ( 338), but nevert he less per sistent foll ow-up is essentia l to e nsure a gainst loss of reduction a fter either non operativ e or operative manage ment. No no per ative metho ds may no t be su itable for fra ctu res inv olvin g articula r surfaces such as th e ankle or th e kn ee. Here accurate restoration of articular an atomy is the idea l. Nevertheless, closed re ducti on by l igamentotaxis wi th or with out percutaneous fixa ti on of peri articu lar fractures is often p re ferable to o pen re duc tion an d attempted rigid f ixat io n of ar ticula r fra ctu res tha t may devascula ri ze sma ll commi nuted fracture fra gments (235).
Advantages of Operative Treatment

Th e primary adva ntage of operative tre atment is that well-performed fracture fixati on permits a nato mic al ignm ent (339 ) P.2 03 o f the fra gm ents, ea rly restoratio n of jo int and mus cle functio n, and rapid mobiliza ti on of th e pa ti ent. Th e ea rly restora ti on of mo bility for patien ts with m ultiple injuries dim in ishes systemic co mplications su ch a s phlebi ti s, pulmo nary embolism, and c ardiorespira to ry pro blems. The minima lly invasive me th ods of close d reduction and cl osed nailing or percutaneous screw fixation come close to the idea l o f ef fective fracture imm o bilization wi th ea rly patie nt mo bilizatio n. Ho wever, this idea l is not alw ays a chieved an d ine ffecti ve fixat io n i s wors e than no ne at all.
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FIGURE 5 -66 A. Anteropo ste ri or x -ray of a pa ti ent wi th bila teral cen tra l a ceta bula r fra ctu re s treated initial ly in traction f or 3 weeks. The traction wa s gradua lly de creased and th e pa tie nt was allowed out of bed. B. Fo llow -up x-rays wh en the tra ctio n was de crea sed sho wed furth er protrus io n of the fem oral hea d in to the a cet abula r fr a ctu re o n th e le ft. T he fracture h ad inv olved the anterio r an d po ste ri or co lumns, and therefore was mo re unstable than the fra ctu re o f th e righ t hip. The patient was placed ba ck in bilatera l tract io n for an additio nal 3 weeks. C. X-rays of the pelvis a t 2 years sh ow adequ ate healin g of both acetabu lar fractures with main tenan ce o f the art iculatio n o f the femo ral head wit h t he acetabul ar do me bi laterally. Th e patien t ha d a f ull ra nge of mo tion in the right h ip a nd sli ght limita ti on of ro tation in the lef t but was asymptoma tic with close to normal symmetric relationships between he r fe moral heads an d acetabu lor weightbe aring domes.
Disadvantages of Operative Treatment

A signific ant disadvan ta ge of ope ra tive fixatio n is the impedimen t it o ffers to the effective biologic p rocesses of fracture repair (13,16,336). The reader should recall that the classic Wolff's law of bone fo rma ti on might be summarized simply as statin g that b one respon ds to the need for it (340). Th e introduction of mechan ical fixation of fracture fragments temporarily inhibits or perman ently alters signals to the repair processes of bone. W hen a fra ctu re is subjected to compressi on by e ither a plate o r externa l fixator, callus forms in re spo nse to th e co mpressive lo ading (9,10 ,341 ,34 2). Ho wever, th e call us is weak when lo aded in ten sion . Thus, a sign ifican t nu mb er of fra ctur e s that have been t reated by co mp ressio n plating or co mpressi on fix ators have been reported to fail once th e plate or the external fixator is removed du e to th e inability of the seem ingly repaired fra cture to resist tensile lo ad (1 0,259,260,2 61,262). Th is p heno meno n has been no te d to pers ist for seve ra l ye ars un til the callu s can be modeled to align its elf i n th e normal lon gitudina l axis o f th e bone, and thereby bec ome capabl e of r esistin g ten sio n as w ell a s compressive loa ding. Th e ma nagemen t of fractures co ntin ues to evo lve. Ultimately, our goal sh oul d be to maximize cl osed re duc ti on of f rac tur es a nd minimize inva sive surgery. As we have slowl y gain ed so me u nder standi ng o f the phen omen al proc esses of ske letal re pair, man y use ful bio logic (3 43,344 ,345 ) an d cellu lar (5 ,6,11 ,339,340) methods h ave become availa ble to a id the se repai r processes . Consequ ently, th e
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tru ly skilled physician wh o tre ats f ra ctures must a ppreciate th e biolo gic cultiva tio n of h ealin g as well a s the carpentry of fracture fixation. P.2 04
ACKNOWLEDGEMENTS
Th e author deeply apprec ia tes the critiqu e of t his revi se d cha pte r by Steve Nguyen , MD a nd other co lleagu es in the o rth opae dic residenc y program at O rl ando R egion al Hospital, Florida. Also , the v alua ble tec hn ical assi sta nce of Mrs. Ver onica R ichards on in revising this ch apter is sincer ely a ppreciated.
REFERENCES
1. Ma nola gas S, Ji lka R. Bo ne mar row, cytokines, and bon e remo delin g. N Engl J Med 199 5;33 2:30 5 310 .
2. Gal lagher G. Evolutio ns: Bo ne ma rrow hem ato poie sis. J NI H Res 19 94; 6 :9 5 97 .
3. Gul ati G L. Str uctur e and function o f the bone mar ro w a nd h emato poies is. He matol Onco l C lin No rth Am 19 88 ;2:495 5 11.
4. Kessin ger A. Circulatin g stem cel ls W axing hema to poi eti c. N E ngl J Med 199 5;33 3:31 5 316 .
5. C aplan A. Me se nchymal stem cells. J Orthop Res 19 91;9 :641 6 50.
6. F errari G, DeAn gelis G, Col etta M , e t al. M uscle rege neratio n b y bone m arrow-derived myogenic proge nitors. Scien ce 1 998 ;279 :152 8 153 0.
7. Boorstin D. Bergson's creative evolution. In: Boorstin D. Th e seekers. Ne w York: Ran dom Hous e, 19 98:2 45 24 9.
8. Kenwright J, Goo dship A. Controlle d mecha nical sti mu latio n i n th e treatm en t of tibi al fractures. C lin Ort hop Rel Res 19 89;2 41:3 6 47.
9. O lerud S, Danckwardt- Lilliestr o
m G. Frac tur e hea ling in comp ression o steo synthesis. Acta
Orth op Scand Suppl 197 1;13 7:1 44 .
10. Wirth C, Campbel l C , Askew M, et a l. The biome ch anical effects of compression pla tes applied to fractures. J Tra uma 19 74;1 4:56 3 571 .
11. Co nnolly J. Avoida ble cau ses of non-u nio n. C lin Ort hop Rel Res 19 85;1 94:22 6 23 2.
12. Heppenstal l R, Bright on C , Esterha i J, e t al. Progn ostic f actors in non unio n of the tibia: An evalua tion o f 185 cases tre ated w ith co nstant direct current. J Trauma 19 84;2 4:790 7 96 .
13. McK ibben B. The bio logy of frac tur e healin g in lo ng bone s. J Bone Joint Su rg 197 8;60 B:1 50 1 62.
14. Rhin elan der F , Gracilla R, Phill ips R, et al . Microan giogra phy i n bo ne hea ling. III. Oste otomie s with inter na l fixatio n. J Bone Join t Surg 196 7;49 :100 6.

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Ovid: Rockwood & Green's Fractures in Adults

Edi tors : Tit le:

Buchol z, Robe rt W.; Heckm an, J ames D.; Court-Brown , Charl es M.

C opyright 2006 Lippincott Willia ms & Wilki ns

Chapter 5 Nonoperative Fracture Treatment

EFFECT OF TREATMENT ON SKELETAL REPAIR PROCESSES

A BRIEF HISTORY OF THE EVOLUTION OF FRACTURE TREATMENT

Ovid: Rockwood & Green's Fractures in Adults

TABLE 5-1 Chronology of Nonoperative Fracture Treatment

Hippo cra tes

Ovid: Rockwood & Green's Fractures in Adults

Co lles and Sm ith frac tur e.

Ovid: Rockwood & Green's Fractures in Adults

Cru tch field

Ovid: Rockwood & Green's Fractures in Adults

SELECTION OF FRACTURES FOR NONOPERATIVE TREATMENT AND ACCEPTABILITY OF REDUCTION

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

OPTIONS IN NONOPERATIVE MANAGEMENT OF FRACTURES

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Fractures of the Scapula

Ovid: Rockwood & Green's Fractures in Adults

Proximal Humeral Fractures

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Humeral Shaft Fractures

Ovid: Rockwood & Green's Fractures in Adults

Fractures of the Head of the Radius

Ovid: Rockwood & Green's Fractures in Adults

Isolated Fractures of the Ulna

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Fractures of the Carpal Scaphoid

Ovid: Rockwood & Green's Fractures in Adults

with perm iss ion.)

Phalangeal and Metacarpal Fractures

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Fifth Metacarpal Fractures

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Fractures of the Lateral Malleolus

Ovid: Rockwood & Green's Fractures in Adults

Fibula Shaft Fractures and the Maisonneuve Fracture

Ovid: Rockwood & Green's Fractures in Adults

Stress Fractures and Other Undisplaced Tibial Fractures

Ovid: Rockwood & Green's Fractures in Adults

Intertrochanteric and Femoral Neck Fractures

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Anterior Pelvic Ring Injuries

Ovid: Rockwood & Green's Fractures in Adults

Posterior Pelvic Ring Injuries

Ovid: Rockwood & Green's Fractures in Adults

SPINAL INJURIES Cervical Spine Fractures

Ovid: Rockwood & Green's Fractures in Adults

Central Cord Injuries

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Bracing of Cervical Spine Injuries

Thoracic and Thoracolumbar Fractures

Ovid: Rockwood & Green's Fractures in Adults