CONSERVATIVE CONSERVATIVE TREATMENT OF TREATMENT OF

FRACTURESFRACTURES

Dr. Muhammad ASIFDr. Muhammad ASIF

Orthopedic SurgeonOrthopedic Surgeon

Department of OrthopaedicsDepartment of Orthopaedics

College of MedicineCollege of Medicine

King Khalid University HospitalKing Khalid University Hospital

Fracture managementFracture management

The ideal goal of fracture management is The ideal goal of fracture management is anatomical reduction and function restoration anatomical reduction and function restoration compatible with the severity of injury, age, compatible with the severity of injury, age, occupation and activity of daily living of injured occupation and activity of daily living of injured patient.patient.

Either Either OperativeOperative Non operative (ConservativeNon operative (Conservative))

TractionTraction Splint (Cast / Slab)Splint (Cast / Slab)

TractionTraction

TractionTraction is the application of a pulling force to a is the application of a pulling force to a part of the body part of the body

Purpose:Purpose: to reduce, align, and immobilize fractures;to reduce, align, and immobilize fractures;

• Unstable and unfixableUnstable and unfixable When reduction and/or proper length cannot be When reduction and/or proper length cannot be

maintained by static immobilizationmaintained by static immobilization to minimize muscle spasmto minimize muscle spasm to prevent or reduce skeletal deformities or muscle to prevent or reduce skeletal deformities or muscle

contractures.contractures.

Classification of TractionClassification of Traction

Skin Traction Skin Traction : : is maintained by direct application is maintained by direct application of a pulling force on the patient’s skin . Generally of a pulling force on the patient’s skin . Generally temporary measure. To reduce muscle spasms To reduce muscle spasms To maintain immobilization before surgeryTo maintain immobilization before surgery In childrenIn children

Skeletal Traction Skeletal Traction : : applied to bone by means of a applied to bone by means of a pin or wire surgically inserted into the bone, pin or wire surgically inserted into the bone, providing a strong steady, continuous pull, and providing a strong steady, continuous pull, and can be used for prolonged periods . can be used for prolonged periods .

Complications of tractionComplications of traction

Neurovascular compromise.Neurovascular compromise. Inadequate fracture alignment..Inadequate fracture alignment.. Skin breakdown .Skin breakdown . Soft tissue injurySoft tissue injury Pin tract infection .Pin tract infection . Osteomyelitis can occur with skeletal traction.Osteomyelitis can occur with skeletal traction.

Complications of tractionComplications of traction

complications from immobility especially with complications from immobility especially with long term traction and in elder pt.long term traction and in elder pt.

Pressure ulcer Pressure ulcer Pneumonia Pneumonia ConstipationConstipation Anorexia Anorexia Urinary stasis and infection Urinary stasis and infection Venous stasis with DVT Venous stasis with DVT

General Indications for CASTGeneral Indications for CAST

1. Most fractures in children:1. Most fractures in children:a. Tremendous capacity of remodeling.a. Tremendous capacity of remodeling.b. Non union and stiffness is unlikely.b. Non union and stiffness is unlikely.

2. Undisplaced fracture2. Undisplaced fracture3. 3. Poor bone Quality: Osteoporosis.Poor bone Quality: Osteoporosis.4.4. Unfixable fracture e.g. severe comminuted.Unfixable fracture e.g. severe comminuted.5.5. Systemic contraindication.Systemic contraindication.6.6. Local contraindication.Local contraindication.7.7. Psychosocial problem.Psychosocial problem.

Splint / CastSplint / Cast

Principle:Principle: To stabilize joint above and joint below the site To stabilize joint above and joint below the site

of injury whenever and wherever is possibleof injury whenever and wherever is possible Objectives:Objectives:

To hold broken bone anatomically to prevent To hold broken bone anatomically to prevent malunion.malunion.

To reduce excessive movements to prevent To reduce excessive movements to prevent non union.non union.

To get early functionTo get early function

How to Preserve Function?How to Preserve Function?

Immobilize only joint necessary,Immobilize only joint necessary, Range of motion of uninvolved joints.Range of motion of uninvolved joints. Isometric exercise.Isometric exercise. Physiotherapy after cast removal.Physiotherapy after cast removal. Weight bearing whenever possible in case Weight bearing whenever possible in case

of lower limb fracture.of lower limb fracture.

What are casts made of ?What are casts made of ? The outside, or hard part of the castThe outside, or hard part of the cast, ,

two different kinds of casting materials.two different kinds of casting materials. Plaster (POP)Plaster (POP) - white in color.  - white in color.

hemihydrated calcium sulphate.hemihydrated calcium sulphate.

On adding water it solidifies by an exothermic reaction into On adding water it solidifies by an exothermic reaction into hydrated calcium sulphatehydrated calcium sulphate

fiberglassfiberglass - variety of colors, patterns, and designs. - variety of colors, patterns, and designs.

inside of the cast inside of the cast

Cotton and other synthetic materials are used to line Cotton and other synthetic materials are used to line thethe inside of the cast to make it soft and to provide inside of the cast to make it soft and to provide padding around bony areas.padding around bony areas.

PlasterPlaster is usually used in the early stages of is usually used in the early stages of treatment,treatment, Displaced Fracture that need manipulationDisplaced Fracture that need manipulation can be molded more precisely.can be molded more precisely. heavy heavy must remain dry, water will distort the castmust remain dry, water will distort the cast  

FiberglassFiberglass Can be used in Undisplaced Fx if swelling not expectedCan be used in Undisplaced Fx if swelling not expected healing process has already started.healing process has already started. lighter weight, durable, require less maintenancelighter weight, durable, require less maintenance..

Different types of castsDifferent types of casts

Type of Cast/Slab Location Uses

Short arm Applied below the elbow to the hand.

Distal Forearm or wrist Fx. Also used to hold the forearm or wrist muscles and tendons in place after surgery.

Long arm Applied from the upper arm to the hand.

Distal humerus, elbow, or proximal forearm fractures. Also used to hold the arm or elbow muscles and tendons in place after surgery.

Scaphoid cast/ thumb spica

Below elbow to hand including thumb

Scaphoid Fx, thumb FX

U slab From shoulder to elbow and then to armpit

Humerus shaft fx

Type of Cast / Slab Location Uses

Short leg cast: Applied to the area below the knee to the foot.

Distal T/F Fx, ankle Fx, severe ankle sprains/strains.

Long leg cast From above knee to foot Proximal T/F Fx,trauma around knee

Hip spica From lower chest to one or both feet

Femur fracture in children

PTB cast From knee to foot For weight bearing in healing Fx T/F

Closed Reduction MethodClosed Reduction Method

Closed Reduction MethodClosed Reduction Method Adequate analgesia / anaesthesiaAdequate analgesia / anaesthesia Traction – countertractionTraction – countertraction Increase the deformity if needed, to reduce / Increase the deformity if needed, to reduce /

lock on fragmentslock on fragments Correct rotational deformity as well. Correct rotational deformity as well. Remove any rings from fingers or affected limbsRemove any rings from fingers or affected limbs All acute injuries (<48 hours post injury) All acute injuries (<48 hours post injury)

fully padded well molded plaster, fully padded well molded plaster,

full casts may be splittted.full casts may be splittted.

After Closed Reduction and After Closed Reduction and CastingCasting

must have circulation checkmust have circulation check Plaster takes 48 hours to become fully dry Plaster takes 48 hours to become fully dry

and harden so take care.and harden so take care. Weekly radiographs for 3 weeks to confirm Weekly radiographs for 3 weeks to confirm

acceptable reduction.acceptable reduction. Can re-manipulate within 3 weeks after Can re-manipulate within 3 weeks after

injury if displaced.injury if displaced.

Excellent Reduction with Well Excellent Reduction with Well Molded CastMolded Cast

Colles’ FractureColles’ Fracture

Displaced Displaced dorsolaterrallydorsolaterrally

Treatment:Treatment:

Cast +/- surgery, Cast +/- surgery, depending on depending on shortening and shortening and displacementdisplacement

Scaphoid Bone FXScaphoid Bone FX

Retrograde blood Retrograde blood supplysupply

Total healing time of Total healing time of 10-12 weeks or more10-12 weeks or more

Boxer’s FractureBoxer’s Fracture

Classically neck of Classically neck of the the fifth metacarpal

bump over the back bump over the back of palm just below the of palm just below the small finger knucklesmall finger knuckle

Treatment: casting or Treatment: casting or surgery (pinssurgery (pins))

Patellar FracturePatellar Fracture

Fall onto kneecap or Fall onto kneecap or when quadriceps is when quadriceps is contractingcontracting

Attempt “straight leg Attempt “straight leg raise”raise”

If Extensor mechanism If Extensor mechanism intact / undisplaced Fx intact / undisplaced Fx Cast / Slab Cast / Slab

Fracture of 5Fracture of 5thth Metatarsal Metatarsal

Avulsion FractureAvulsion Fracture base of 5th metatarsal from pull of attached base of 5th metatarsal from pull of attached

tendon;tendon; heal well in castheal well in cast

Jones FractureJones Fracture Transverse fracture through base of 5th Transverse fracture through base of 5th

metatarsal, about 1-2 cm from tip;metatarsal, about 1-2 cm from tip; cast for 6-8 wks if undisplacedcast for 6-8 wks if undisplaced

Fracture of 5Fracture of 5thth Metatarsal Metatarsal

Avulsion FxAvulsion Fx

Jones’ fractureJones’ fracture

30 year old patient30 year old patient

Torus FractureTorus Fracture

““Buckle Buckle fracture”fracture”

mostly in mostly in children; children; metaphysismetaphysis

cast for 2-4cast for 2-4

weeksweeks

Type 1 S/C Fx humerus:Type 1 S/C Fx humerus:non-displacednon-displaced conservative conservative

Note the non- Note the non- displaced fracture displaced fracture (Red Arrow)(Red Arrow)

Note the posterior fat Note the posterior fat pad (Yellow Arrows)pad (Yellow Arrows)

Type 2: Angulated/displaced fracture with intact Type 2: Angulated/displaced fracture with intact posterior cortex;posterior cortex;

close reduction and K-wires fixation close reduction and K-wires fixation

Type 3: Complete displacement, with no contact Type 3: Complete displacement, with no contact between fragments;between fragments;

close / open reduction and K-Wire fixation close / open reduction and K-Wire fixation

UNDISPLACED FRCTURE UNDISPLACED FRCTURE LATERAL CONDYLELATERAL CONDYLE

Fracture surgical neck humerus,Fracture surgical neck humerus,10 year old10 year old

Post Cast instructionsPost Cast instructions Keep your limb elevated to prevent swelling. Apply an ice bag to injured area. Keep the cast clean and dry. Check for cracks or breaks in the cast. Rough edges should be padded to protect the skin

from scratches. Do not scratch the skin under the cast by inserting

sticks. Encourage patient to move his/her fingers or toes to

promote circulation

ContdContd

Prevent small toys or objects from being put inside the cast.

Do not put powders or lotion inside the cast. Cover the cast while your child is eating to prevent

food spills and crumbs from entering the cast. Do not use the abduction bar on the cast to lift or

carry the child. Use a diaper or sanitary napkin around the genital

area to prevent leakage or splashing of urine.

How To Know if Something Is How To Know if Something Is Wrong With Your CastWrong With Your Cast

Pain Pain that is not adequately controlled with medication that is not adequately controlled with medication prescribed by your doctor.prescribed by your doctor.

IncreasingIncreasing swelling swelling Numbness or tingling Numbness or tingling in the extremity (hand or foot).in the extremity (hand or foot). Inability to move Inability to move your fingers or toes beyond the cast.your fingers or toes beyond the cast. Circulation problems Circulation problems in your hand or foot. in your hand or foot. Loosening, splitting or breaking Loosening, splitting or breaking of the cast.of the cast. Unusual odorsUnusual odors, sensations, or , sensations, or woundswounds beneath the beneath the

cast.cast. If you develop a If you develop a feverfever or generalized illness or generalized illness

Complications of castComplications of cast

Compartment syndrome, tight cast that restricts Compartment syndrome, tight cast that restricts swelling.swelling.

Impaired distal neurovascular.Impaired distal neurovascular. most serious is deep venous thrombosis leading most serious is deep venous thrombosis leading

to pulmonary embolism----calf pain.to pulmonary embolism----calf pain. Re displacement of fracture.Re displacement of fracture. stiff joints, muscle wasting.stiff joints, muscle wasting. Plaster Sores.Plaster Sores. Malunion, Nonunion, Delayed unionMalunion, Nonunion, Delayed union

Cast Burns- can Cast Burns- can occur during cast occur during cast removal if blade dull removal if blade dull or improper technique or improper technique used.used.

Fracture distal Radius & ulnaFracture distal Radius & ulna

Close reduction and castingClose reduction and casting

Fracture HealedFracture Healed

Fx distal Radius ulna in a ChildFx distal Radius ulna in a Child

After Close reduction and castingAfter Close reduction and casting

One week follow up; AngulatedOne week follow up; Angulated

Surgery; Surgery; close reduction and fixationclose reduction and fixation

HealedHealed

21 year old patient21 year old patient

THANKSTHANKS