Synopsis of Orthopaedic Trauma Management. Brian H. Mullis

      c. Longitudinal traction may not allow the fragments to be disimpacted and brought out to length if there is an intact soft-tissue hinge (typically seen in children who have strong periosteum that is intact on one side).

      d. Reproduction of the mechanism of fracture to hook on the ends of the fracture angulation beyond 90 degree is usually required.

      3. Immobilization:

      a. Fractures must be immobilized to include the joint above and below.

      b. Maintain the position of the bone fragments to the point of healing.

      c. Use splints initially to accommodate for potential swelling.

      d. Three-point contact (mold) is necessary to maintain closed reduction.

      e. Cast must be molded to resist deforming forces.

      4. Cast padding:

      a. Roll the padding distal to proximal.

      b. Use 50% overlap.

      c. Four layers minimum.

      d. At bony prominences, use extra padding: fibular head, malleoli, patella, and olecranon.

      5. Plaster versus fiberglass:

      a. Plaster is better for molding, use cold water to maximize molding time.

      b. Fiberglass is more difficult to mold but is more durable and 2 to 3 times stronger. It is also more resistant to breakdown.

      c. Width of roll: 6 inch for thigh; 3 to 4 inch for lower leg; 3 to 4 inch for upper arm; and 2 to 3 inch for forearm.

      II. Nonoperative Treatment of Displaced Fractures of the Upper and Lower Extremity

      A. Nonoperative treatment with immobilization or closed reduction is suitable for many displaced fractures such as clavicle, scapula, proximal humerus, humeral shaft, ulna, distal radius, vertebral fractures, pelvis, tibia, and ankle fractures.

      B. Patients who are not amenable to operative treatment due to medical comorbidities are candidates for nonoperative treatment.

      C. Clavicle fractures

      1. Non or minimally displaced clavicle fractures:

      a. These fractures heal well with a sling, physical therapy, and range of motion (ROM) exercises.

      b. These return to normal function in 6 to 10 weeks or sooner in children and adolescents.

      2. Midshaft clavicle fractures with > 100% displacement or shortened > 2 cm:

      a. Nonunion rate up to 15% with nonoperative treatment.

      b. These may heal with a symptomatic malunion.

      D. Scapula fractures

      1. Nonoperative management is indicated for the vast majority of extra-articular scapula fractures.

      2. Treatment consists of sling immobilization with early motion as tolerated and physical therapy as needed.

      3. Consideration for operative fixation should be made in cases involving glenohumeral instability, displaced glenoid fractures, and significant medial displacement of the lateral border.

      E. Proximal humerus fractures

      1. Nonoperative management is often recommended for minimally displaced fractures in all patients.

      2. Some studies have reported little or no benefit of operative fixation for 3- and 4-part proximal humerus fractures in elderly low-demand patients.

      3. Conservative treatment involves initial sling application with a progressive physical therapy regimen at 1 to 2 weeks post injury as pain subsides.

      4. A thorough discussion of the indications for operative management of proximal humerus fractures can be found in Chapter 21, Proximal Humerus Fractures.

      F. Humeral diaphysis

      1. The treatment of displaced humeral shaft fractures has been traditionally nonoperative with low nonunion rates and good outcomes.

      2. A modern trend of operative fixation has been generating substantial interest.

      a. Potential indications for surgical management are polytrauma, open fractures, vascular injury, inability to tolerate splinting, body habitus, and pathologic fractures.

      3. Nonoperative management:

      a. Initial treatment with coaptation splint (laterally above shoulder, around elbow, and along the medial arm; pad armpit well).

      b. Conversion to functional bracing within 1 to 2 weeks.

      c. Immobilization with a brace should be employed for 6 to 12 weeks with confirmation of fracture healing radiographically.

      d. Elbow mobilization should begin shortly after the brace has been fitted.

      e. Humerus easily tolerates coronal and sagittal malalignment and 3 cm of shortening. Cosmetic deformities have been noted with 30 degrees of coronal angulation and 20 degrees of sagittal deformity.

      f. Dr. Sarmiento’s series of 620 patients treated with functional bracing for humeral shaft fractures had the following results:

      i. Six percent nonunion in open fractures and < 2% nonunion in closed fractures.

      ii. Most patients healed with < 16 degrees of anterior and varus angulation and achieved good to excellent function.

      G. Forearm

      1. Isolated ulna fractures can be treated with immobilization if there is acceptable alignment (less than 50% translation and less than 15 degrees angulation).

      a. Some authors recommend initial immobilization of both the wrist and elbow, while others feel the elbow can be left free.

      b. Consider transition to ulna fracture bracing at 1 to 2 weeks post injury.

      2. Most isolated radial shaft and both bone forearm fractures benefit from operative fixation in adults as it is difficult to maintain reduction with cast immobilization.

      3. Nonoperative treatment in adults may lead to loss of pronation and supination.

      4. Nonoperative treatment is the standard of care in children if alignment can be maintained in a cast (see Chapter 12, Principles of Pediatric Fracture Management, for specific guidelines).

      H. Distal radius

      1. Many displaced distal radius fractures can be treated with closed reduction and immobilization in a cast or splint.

      2. Traction followed by reduction in flexion and ulnar deviation is usually required to reduce a Colles fracture (two-part extra-articular fracture; Chapter 28, Distal Radius and Galeazzi Fractures, ▶Fig. 28.4).

      3. Immobilize in a splint with molding on the dorsum of the distal radius with slight flexion and ulnar deviation.

      4. Assuming acceptable reduction is obtained, the injury should be closely monitored for maintenance of reduction.

      5. Indications for surgical management of distal radius fractures are discussed in detail in Chapter 28, Distal Radius and Galeazzi Fractures.

      6. Operative treatment, compared to nonoperative treatment, of displaced distal radius fractures in elderly patients has shown better radiographic results but no improvement in functional outcome.

      I. Pelvis

      1. The majority of minimally and nondisplaced pelvic fractures can be treated nonoperatively.

      2. See