Synopsis of Orthopaedic Trauma Management. Brian H. Mullis

Chapter 30, Pelvic Ring Injuries, for a detailed discussion of initial and definitive treatment.

      J. Femoral shaft

      1. Nonoperative treatment of femoral shaft fractures occurs in some third-world hospitals or in patients who are not amenable to operative treatment.

      2. The results of Perkins’ traction (skeletal traction which allows movement of the knee) is reported to have a nonunion/malunion rate up to 10%, pin infection incidence of 30%, and an average hospital stay of 8 weeks.

      3. Intramedullary nailing of femur fractures has been one of the great success stories of 20th century and is the standard of care even in remote hospitals with union rates > 98%.

      K. Tibial shaft

      1. These fractures were commonly treated nonsurgically through the 1970s until intramedullary nailing became more popular.

      2. Techniques such as long leg casting with wedging to correct angular deformity and transition to patellar tendon bearing casts and cast bracing were the standard of care.

      a. Patients were placed in above knee long leg casts and switched to functional braces after 3 to 5 weeks.

      3. Sarmiento reported a 2.5% nonunion rate and < 10% malunion rate in a series of 780 tibial fractures (241 were open).

      a. Union occurred at an average of 17 weeks for closed fractures and 22 weeks for open fractures.

      4. Generally acceptable parameters for closed treatment include < 5 to 10 degrees varus or valgus angulation, < 15 degrees in the sagittal plane, < 15 degrees internal rotation, < 20 degrees external rotation, and < 2 cm of shortening.

      L. Ankle fractures

      1. Most unimalleolar nondisplaced ankle fractures are treated closed.

      2. Unstable displaced ankle fractures are typically treated surgically.

      3. Displaced ankle fractures can be treated nonoperatively if tibiotalar joint congruity is obtained following reduction.

      4. Indications for closed treatment of ankle fractures include:

      a. Isolated lateral malleolus fracture with < 4 mm medial clear space widening on external rotation or gravity stress views.

      b. Isolated medial malleolus fractures where reduction can be maintained in cast.

      c. Elderly low-demand patients or poorly controlled diabetics with high risk for surgical complications.

      5. Displaced bimalleolar and trimalleolar ankle fractures should be promptly reduced even if surgical management is planned.

      6. Typical reduction maneuver for a supination—external rotational injury with lateral talar displacement:

      a. The Quigley maneuver classically describes suspension of the great toe with the patient supine. This facilitates reduction by adduction, internal rotation, and supination of the foot.

      b. Treated with below knee casting for 4 weeks or longer depending on healing.

      III. Casting Techniques

      A. Short leg cast

      1. Support metatarsal heads.

      2. Flex the knee to relax the gastrocnemius muscle.

      3. Position the ankle in neutral dorsiflexion.

      4. Ensure freedom of the toes.

      5. Build up heel for walking casts—fiberglass much preferred for durability.

      B. Long leg cast

      1. Apply the below knee portion first with a thin layer proximally.

      2. Flex the knee 5 to 20 degrees.

      3. Mold the supracondylar femur for improved rotational stability.

      4. Apply extra padding anterior to the patella.

      C. Short arm cast

      1. Metacarpophalangeal joints free and thumb free to the base of the metacarpal.

      2. Distal extent of the cast ends at the proximal palmar crease.

      3. Opposition of the thumb to the small finger should be unobstructed.

      D. Ulnar gutter: https://www.youtube.com/watch?v=kx2YBmq7oS0.

      E. Volar/dorsal hand: https://www.youtube.com/watch?v=Iv-Nigb6aN8.

      F. Thumb spica: https://www.youtube.com/watch?v=864h9gVgmKs.

      IV. Traction Pin Placement

      A. Create a sterile field with the limb exposed.

      B. Administer local sedation +/– sedation.

      C. Insert the pin from the known area of neurovascular structure.

      D. Distal femoral traction

      1. It is the method of choice for acetabular and proximal femur fractures.

      2. Indicated in the presence of a knee ligament injury for femoral shaft fractures instead of proximal tibial traction.

      3. Insert the pin from medial to lateral at the adductor tubercle—slightly proximal to epicondyle.

      E. Proximal tibia traction

      1. It is the method of choice for femoral shaft fractures.

      2. Insert the pin 2 cm posterior and 1 cm distal to the tibial tubercle from lateral to medial.

      3. Incise skin and avoid the anterior compartment by mobilizing the muscle posteriorly with the pin or hemostat.

      F. Calcaneus traction

      1. Typically used when proximal tibia and distal femur traction pins are contraindicated.

      2. Insert the pin medial to lateral 2 to 2.5 cm posterior and inferior to the medial malleolus.

      G. Place sterile dressing around pin site.

      H. Place protective caps over sharp pin ends.

      I. Hang weight from the traction bow.

      1. Fifteen percent of the body weight for distal femur traction.

      2. Ten percent of the body weight for proximal tibia and calcaneus traction.

      V. Complications of Closed Treatment

      A. For select fractures treated nonoperatively, especially those requiring a cast, complication rates can be as high as seen with surgical intervention.

      B. If an unacceptable degree of malalignment develops, it usually occurs early. Correction can be achieved with surgery or cast wedging in select cases.

      C. Cast wedging can be used to improve alignment early in the treatment period.

      1. Measuring the deformity with orthogonal films in the coronal and sagittal planes.

      2. The cast is cut circumferentially leaving a hinge on the convexity of the deformity.

      3. The cast is then distracted on the concave side and a spacer (cork, balsa wood, plastic) is inserted.

      4. The size of the spacer can be approximated by the angle of deformity requiring correction (10 degree correction generally achieved with a 10-mm spacer).

      5. The cast is overwrapped with plaster or cast material.

      D. Casts and splints carry the risk of causing a pressure sore.

      1. Typically occurs over a bony prominence.