Non Operative Fracture

treatment

Introduction
A facture is a break in structural continuity of
bone

It may no more than a crack, a crumpling or a

splintering of the cortex; more often the break is
complete and the bone fragments are displaced
If the overlying skin remain intact it is closed (or
simple) fracture, if the skin or one of the body

cavities is breached it is open (or compound)

fracture, liable to contamination and infection
(appley , 1993)

History of non
operative tx
3000bc imhotep use wood and
splint bandages
1821 barton describes
greenstik fracture and distal
radius
1875 thomas develop thomas
splint
1907 Steinman described

using for distal femur #

1936 Cructhfield develop
skull tong for cervical #

CRITICISM OF CLOSED FUNCTIONAL

TREATMENTS

Arguments against the nonsurgical treatment of

certain fractures, such as the closed diaphyseal
tibia, have been based on claims that the

complication rate from such treatments and their

subsequent surgical correction constitute a cost

greater than that of primary surgical care.

This argument rings hollow, as the evidence clearly
contradicts it.

CRITICISM OF CLOSED FUNCTIONAL

TREATMENTS
Table 2 Estimated Cost of Treatment With Tibial Intramedullary Nail
Initial emergency room visit
Preoperative laboratory examination
Operating room cost based on 90-minute operative time
Surgeon's fee
Anesthesiologist's fee
Cost of intramedullary nail
Follow-up radiographic examination based on five examinations at
$68/2-view series
Inpatient hospital stay based on 3-day stay at $480/day
Total estimated cost of intramedullary nail
Table 3 Estimated Cost of Treatment With Tibial Fracture Brace
Initial emergency room visit
Orthopaedic surgeon's fee
Cost of prefabricated fracture brace
Orthotist fee to follow brace
Follow-up office visits based on eight visits at
$60/visit
Follow-up radiographic examination based on 8
examinations at $68/2-view series
Total estimated cost of closed treatment

$ 707
$ 250
$1754
$1530
$ 540
$ 250
$ 340
$1440
$6811
$ 707
$ 650
$ 200
$ 200
$ 480
$ 544
$2781

OPTIONS IN NONOPERATIVE MANAGEMENT OF

FRACTURES
The basic methods of nonoperative fracture management include
reduction by traction and manipulation of the fracture followed by
immobilization of the reduced fracture using casts, splints, braces, or
other techniques.
Pain relief is best accomplished using local methods including the
technique of rest, ice, compression, and elevation (RICE).

A whole variety of factors influence the selection of treatment options.

For many common fractures, an objective analysis of risks and
benefits will strongly favor non operative treatment.

INITIAL STEPS IN ACUTE REDUCTION OF

FRACTURES
Direct application of traction is among the first

essential steps to reduce a deformed fractured limb.

One historic method has been with a Thomas splint, which was

developed by H. Owen Thomas in England and introduced

during World War I by Sir Robert Jones
The patient then can be transported in reasonable comfort to the
emergency facility.

INITIAL STEPS IN ACUTE REDUCTION OF

FRACTURES

INITIAL STEPS IN ACUTE REDUCTION OF

FRACTURES
Skin Traction
The use of skin traction to align a fracture, particularly of the
femur, has been common since it was popularized by Buck in
the Civil War
Skin is unable to tolerate more than approximately 6 to 8
pounds of traction for a brief length of time.
Heavier or prolonged traction tends to pull off the superficial
layers of the skin and can cause pressure necrosis of soft tissues.

INITIAL STEPS IN ACUTE REDUCTION OF

FRACTURES
The basic technique of
Buck's skin traction is to
apply padding around bony
prominences of the
malleoli. Traction tapes are
then applied to the skin and
an elastic bandage is
wrapped from the ankle to
the knee
The end of the tape is then
attached to the traction
apparatus

Application of Skeletal Traction

The preferred method of applying traction for most fractures is by

inserting a threaded Steinmann or Bonnell pin into the distal
fracture fragment and then applying traction weights directly to it.
If local anesthetic is used, the anesthesia should be infiltrated
down thoroughly to the sensitive periosteum. The skin should be
incised prior to inserting this traction pin to avoid irritation from
the pin.

Application of Skeletal Traction

The preferred method of applying traction for most fractures is by

inserting a threaded Steinmann or Bonnell pin into the distal
fracture fragment and then applying traction weights directly to it.
If local anesthetic is used, the anesthesia should be infiltrated
down thoroughly to the sensitive periosteum. The skin should be
incised prior to inserting this traction pin to avoid irritation from
the pin.

Application of Skeletal Traction

A wide variety of

traction techniques
are available that
allow treatment of
fractures from the
cervical spine
down to the foot

Application of Skeletal Traction

Once the pin is

inserted, the limb

is immobilized on
some type of
support

Hazards of Skeletal Traction

Although skeletal traction has been proven to be a very reliable and
useful method of reducing and maintaining alignment of many
different fractures, it can occasionally be associated with
complications.
Pin tract infection can be managed by
having the pin pass through the least amount of soft tissue possible
minimizing movement of joints adjacent to the traction pin
cleansing the skin-pin interface with peroxide and applying an antibiotic
ointment

One of the most common complications from skeletal traction is

overdistracting the fracture

Techniques of Cast Application

A plaster-of-paris cast is useful to immobilize most fractures, whether
treated non operatively or operatively
The plaster-of-paris bandage consists of a roll of muslin stiffened by a
starch and impregnated with a hemihydrate of calcium sulfate
When water is added, the calcium sulfate crystallizes (CaSO4 H2O +
H2O = CaSO4 2H2O + heat).
Before applying a cast, check the CMS (circulatory, motor, and
sensory) status of the limb

Techniques of Cast Application

The plaster cast is
applied in layers by

molding with the base

of one's hand
Since the limb swells
after the fracture, it is
important to elevate

the limb in the cast to

allow drainage from
the extremity

Techniques of Cast Application

Cast removal requires an oscillating
type of saw that generates dust that is
lower in quantity and larger in particle
size than the dust generated on removal

of plaster-of-paris casts.
It is best to support the cast with the

thumb held against the cast in order to

avoid pushing the blade through the
patients' skin

SOME EXAMPLES OF NON OPERATIVE

TREATMENT
Forearm Fractures
Forearm fractures result from failure in compression or tension or
both. Compression failure produces the characteristic torus fracture of
the child's distal radius, or the impacted Colles' fracture in the older

adult
The usual position of the forearm at the time of fracture is in
supination. This causes the greenstick fracture as well as the adult
shaft fracture to angulate in a volar direction. If the fall occurs with
the forearm pronated, the torsional mechanism produces a fracture

that angulates dorsally.

SOME EXAMPLES OF NON OPERATIVE

TREATMENT

SOME EXAMPLES OF NON OPERATIVE

TREATMENT
To reduce these fractures, the

torsional mechanism should

be reversed.
This is done not by

hyperextending or
hyperflexing the deformity but
reversing either the supinated
or pronated forearm.

SOME EXAMPLES OF NON OPERATIVE

TREATMENT
Colles' fracture is typical of
the pattern of fracture of
osteoporotic bone in
postmenopausal women
The Colles' fracture produces
a typical dinner-fork
deformity, which includes an
abrupt prominence of the
distal radius and carpus

SOME EXAMPLES OF NON OPERATIVE

TREATMENT
The method of reducing
Colles' fracture or any
fractures is to reverse the
original mechanism of injury.
With adequate anesthesia an
assistant holds the elbow and
offers countertraction

SOME EXAMPLES OF NON OPERATIVE

TREATMENT
Because of the tendency of
Colles' fractures or any
fractures in this area to swell,
the preferred initial
immobilization is with a
sugar-tong splint. The position
of the wrist is maintained by
an assistant using steady
traction on the elbow and
hand

The sugar-tong splint can

usually be changed to a shortarm cast as the swelling
subsides 1 to 2 weeks after the
original injury

SOME EXAMPLES OF NON OPERATIVE

TREATMENT
Tibial Fractures
The consistent pattern of a

tibial fracture sustained by an

indirect torsional mechanism
failure is a fracture line
through the isthmal section of
the tibia
The proximal fragment
displaces medially and
anteriorly relative to the distal

fragment.

SOME EXAMPLES OF NON OPERATIVE

TREATMENT
Tibial Fractures
In applying a cast to a

fractured tibia, it is important

that both the patient and the
person applying the cast
should be comfortable
The patient should be sitting or
lying supine on a stable cast
table and not leaning forward
from a wheelchair of a similar

mobile support

SOME EXAMPLES OF NON OPERATIVE

TREATMENT

SOME EXAMPLES OF NON OPERATIVE

TREATMENT

By 2 to 3 weeks the long leg cast may be changed to

a short leg patella tendonbearing (PTB) cast or a
fracture brace.

While the long leg cast may continue to be used, the

major advantage of the short leg PTB cast or a

fracture brace is that the patient is usually able to

return to work or school more rapidly and have a
sense of being able to function more normally

SUMMARY
The term non operative is misleading since any
closed reduction of a fracture should be considered
an operative procedure and approached with
appropriate care and planning.

Closed reduction, by non operative minimally

invasive methods, remains the treatment
of choice for many fractures today.
The objective is to reduce the fracture by
manipulation and/or traction, assess the reduction
clinically and radiographically