Conservative treatment of fractures

Conservative management of fractures comprises closed reduction, immobilization, and supportive care. Conservative management is the definitive treatment for closed, stable, and/or simple fractures; it is generally contraindicated in open, unstable, and/or complex fractures. The closed reduction technique and type of immobilization device used are determined based on the individual patient and injury. Splinting is preferred over casting for the initial immobilization of most fractures because it better accommodates secondary swelling and is therefore associated with a lower risk of compartment syndrome and other pressure-related complications. Neurovascular exams of the extremity are required before and after immobilization to assess for such complications. Supportive care consists of analgesia and thromboprophylaxis. Most affected individuals can receive outpatient care with short-term follow-up (e.g., 3–7 days); those with uncontrolled pain and/or the inability to perform activities of daily living may need to be admitted. Compartment syndrome, the most significant complication of fracture management, is threatening to life and limb; patients should be educated on compartment syndrome symptoms and return precautions.

General principles ^[1][2][3]

• Conservative fracture treatment primarily consists of immobilization with or without closed reduction.
• It can be started as initial management or continued as definitive management depending on fracture and patient characteristics.
• Reduction and immobilization techniques vary depending on multiple factors
• Orthopedics consultation during the index visit or in follow-up is recommended for most patients.

All suspected acute extremity fractures should be immobilized early to control pain and prevent complications.

Treatment options ^[1][2][3]

• Vary depending on patient and fracture characteristics
• Examples include orthopedic splints, orthopedic casts, and other devices (e.g., slings, braces, bandages)
• An orthopedic splint is often used initially; it may later be replaced with an orthopedic cast for definitive immobilization

• Acute treatment for most extremity injuries
• Definitive treatment for certain fractures, including many pediatric fractures
• Fractures in patients with contraindications to surgical fracture management

• General: fractures requiring surgical fracture management (e.g., open fractures)
• Splints: no absolute contraindications for immediate immobilization ^[2][4]
• Casts ^[1]
  • At risk for compartment syndrome (e.g., significant edema)
  • Soft tissue or joint infections
  • Unsuccessful closed reduction

We list the most important contraindications. The selection is not exhaustive.

Casts and splints are made of a rigid material (plaster or fiberglass) underlaid by stockinette and soft padding to protect the skin and held in place by an elastic bandage overwrap.

Splinting and casting material ^[1][4][5]

• Plaster
  • Types
    • Rolls , strips , prefabricated rolls
    • “Fast drying” or “extra-fast drying”
  • Advantages: more time to fashion and mold
  • Disadvantages: longer application time, heavier, more easily damaged by water, higher risk of skin burns
• Fiberglass
  • Options: rolls, prefabricated strips
  • Advantages: fast application time and lightweight ^[6]
  • Disadvantages: limited time to fashion and mold
• SAM splint: a moldable splint made of soft aluminum with a foam coating that is mainly used in emergency settings to quickly and temporarily immobilize broken extremities.
• Prefabricated splints
  • Options: large variety (e.g., finger, wrist, ankle, knee)
  • Advantages: no preparation required, easy and quick application
  • Disadvantages: limited customization options, less effective immobilization

Heat released during the plaster or fiberglass setting process may lead to thermal injuries, especially with fast-drying plaster. ^[2][7]

Adjunct splinting and casting materials ^[1][4][5]

• Stockinette
  • Applied directly to the skin
  • Protects the skin and wicks away sweat
• Cast padding
  • Wrapped circumferentially in 2–3 layers around the extremity
  • Prevents soft-tissue pressure injury
• Elastic compression bandage
  • Wrapped loosely around the entire splint or cast and secured with metal clips
  • Holds the splint in position
• Others (e.g., stretch-conforming gauze): can be added in different stages depending on local practice

Width and thickness selection ^[1][4][5]

Width

Splinting material, stockinette, and padding width are chosen based on the extremity to be treated.

• Hands and digits: 1–3 inches
• Upper extremity: 3–4 inches
• Lower extremity: 4–6 inches

Thickness

Injuries without fracture characteristics requiring urgent orthopedic consultation can be initially managed conservatively with closed reduction and immobilization. Definitive management varies depending on fracture characteristics; orthopedic casting or operative management may be required.

Closed reduction ^[3]

• Definition: nonsurgical manipulation of a fractured bone (and/or dislocated joint) to restore its normal position and anatomic alignment
• Techniques
  • Vary depending on the type and location of fracture
  • Typically performed by recreating and reversing the mechanism of injury
  • Often involves skeletal traction

Immobilization ^[2]

• Goals: prevent fracture displacement, reduce pain, and protect the damaged area from injury
• Duration: varies depending on patient and fracture characteristics but generally lasts 4–8 weeks.
• Techniques: vary based on patient and fracture characteristics

Options

• Orthopedic splint: a rigid noncircumferential appliance used to immobilize a bone and/or joint
  • Preferred method in the acute setting
  • Accommodates injury-related swelling
  • Insufficient for definitive management of unstable injuries
  • Can consist of prefabricated appliances or custom-made ones using casting and splinting materials
  • See “Upper extremity splints” and “Lower extremity splints.”
• Orthopedic cast: a rigid circumferential appliance used to immobilize a bone and/or joint
  • Provides better immobilization than a splint
  • Does not accommodate injury-related swelling; increases the risk of compartment syndrome
  • Increases the risk of skin breakdown and pressure-related injuries
  • Made of casting materials
• Others
  • Soft removable appliances: e.g., slings, bandages, braces
  • Hard removable appliances: e.g., walking boot
  • Skeletal traction devices: e.g., halo device

Splinting is preferred over casting for immobilization in acute care settings. ^[2]

Perform a neurovascular exam before and after splint or cast application.

Skeletal traction ^[8]

• Definition: the application of a pulling force on an injured body part to help realign shortened, angulated, and/or displaced fractures, and/or reduce joint dislocations
• Goal: to overcome overlying muscle spasm and maintain anatomic alignment of the bones and joints
• Clinical applications
  • Short-term traction (manual or device-based) is a component of many closed reduction techniques.
  • Long-term traction devices (e.g., using braces, pulleys, and/or weights) can be used for immobilization in both conservative and postsurgical fracture management.

Orthopedic splints

The choice of splint is determined by fracture location and characteristics.

Other immobilization devices

E.g., slings, bandages, braces, and orthotic devices made of flexible and/or elastic materials that are easily removable.

Clinical applications

Can be used in both initial and definitive management.

• Proximal humeral fractures
• Shoulder dislocations
• Clavicle fractures
• Scapular fractures
• Adjuncts to orthopedic splints

Shoulder immobilizers

• Affected arm position
  • Shoulder adducted and internally rotated
  • Elbow flexed to at least 90°
• Arm sling
  • Bandage wraps the affected extremity's wrist, forearm, and elbow joint around the unaffected shoulder
  • Supports the weight of the arm and limits movement of the affected shoulder
• Sling and swathe
  • Sling supports the weight of the arm
  • Swathe: an additional bandage that wraps the arm against thorax to prevent external rotation at the shoulder
• Desault bandage: Bandages wrap the affected shoulder joint, upper arm, and elbow joint around the thorax.
• Gilchrist bandage
  • One bandage wraps around both shoulders and affected wrist to support the weight of the arm and prevent external rotation at the affected shoulder
  • Another bandage wraps the distal upper arm against the thorax

Others

• Buddy taping
  • Clinical applications: mostly used for soft-tissue finger injuries; seldom appropriate for finger fractures ^[10][11]
  • Description
    • The affected finger is bandaged to an unaffected finger with gauze applied in the interdigital space to prevent skin irritation and maceration.
    • Can be combined with finger splints
• Clavicle bandage
  • Mainly for medial clavicle fractures or acromioclavicular joint injury
  • The bandage applies pressure on the clavicles and retracts the scapulae.

Orthopedic splints

The choice of splint is determined by fracture location and characteristics.

Other immobilization devices

Walking boot

• Clinical applications
  • Soft tissue injuries of the ankle
  • Isolated nondisplaced lateral malleolar fractures
• Description
  • Prefabricated, removable boot secured with velcro straps
  • Removable for personal hygiene
  • Allows easy transition to weight bearing

Hard shoe

• Clinical applications
  • Foot or toe fractures
  • Soft tissue injuries of the foot
• Description
  • Applied like a sandal, secured with velcro or ties
  • Often combined with buddy taping
  • Primarily used for pain reduction

Buddy taping

• Clinical applications: uncomplicated phalangeal fractures of the lesser toes ^[13]
• Description
  • The affected toe is bandaged to an unaffected toe with gauze applied in the interdigital space to prevent skin irritation and maceration.
  • Often combined with a hard shoe

Supportive treatment

• Periprocedure ^[1][3][4]
  • Oral or parenteral analgesia
  • Consider regional anesthesia or procedural sedation.
  • Open wound treatment prior to splint/cast application
• Aftercare ^[1][2][3]
  • Elevation of the affected extremity above heart level for 48–72 hours
  • Pain management for fractures ^[4]
  • Cryotherapy
  • Progressive mobilization and loading as dictated by fracture type and severity
  • Consider VTE prophylaxis if immobilizing the lower extremity. ^[14]

Cast care instructions ^[1][2]

• Keep casting and splinting material dry.
• For bathing, drape two plastic bags over the bandaged extremity and tape them to the skin.
• Do not push foreign bodies into the cast (e.g., to scratch itchy skin).
• Seek urgent medical attention if clinical features of compartment syndrome occur.

Disposition ^[3]

• For inpatients who sustain fractures while admitted, consult orthopedics, assess patient safety, and determine if the local incident reporting system should be activated.
• Most emergency department patients treated conservatively can be discharged after appropriate workup, immobilization, supportive care, and discharge planning is complete.
• Outpatient follow-up (e.g., orthopedics, family medicine, return visit to emergency department) is typically required within 3–7 days.
• Indications for admission for conservatively treated fractures include:
  • Inability to ambulate safely
  • Inability to perform ADLs
  • Risk of developing permanent disability
  • Inadequate pain management

Discharge planning ^[3]

• Consider geriatrics consultation in older adults at risk of functional decline.
• Consider physiotherapy and/or occupational therapy evaluation in patients with frailty and/or other disabilities.
• Consider screening for domestic violence, older adult abuse, and child abuse in at-risk patients.
• Provide aftercare instructions, including:
  • Guidance on immobilization method and fracture care (e.g., cast care instructions)
  • Restrictions for weight-bearing, activity, and work
  • Return precautions and monitoring for complications of conservative fracture management
• Provide a copy of relevant radiology reports.
• Ensure appropriate and timely follow-up.

• Fracture complications (e.g., fat embolism, malunion, contracture)
• Complications of immobilization (e.g., VTE, pneumonia)
• Complications of poor technique ^[1][4]
  • Thermal injury
  • Conversion to open fracture
  • Pressure ulcers
• Complications of casting/splinting ^[4]
  • Compartment syndrome ^[1]
  • Ischemic injury, e.g., Volkmann contracture
  • Infection
  • Dermatitis, pruritus
  • Cast related pain

Compartment syndrome is a life- and limb-threatening emergency. Promptly remove the constricting cast or splint and assess the limb of any patient with clinical features of compartment syndrome.

We list the most important complications. The selection is not exhaustive.