General principles of definitive fracture management Literature review current through: Sep 2013.

| This topic last updated: ene 31, 2013. INTRODUCTION Immobilization provides the basis for fracture healing. For many complex and unstable fractures, immobilization is achieved by means of internal fixation. However, many stable fractures at low risk of displacement can be immobilized effectively with casting, which can be performed by orthopedists or knowledgeable primary care clinicians. The basic principles and techniques of casting and the follow-up care needed for patients treated in this manner are reviewed here. The assessment and initial management of acute fractures is discussed separately. (See "General principles of fracture management: Bone healing and fracture description" and "General principles of acute fracture management".) CASTING Overview Casting is standard treatment for many closed, nondisplaced, or reduced fractures [1]. Casts provide a stable, protected environment in which the external, periosteal callus can form and normal bone healing can proceed [2]. The optimal time to place a cast is after post-traumatic swelling has resolved. This usually takes five to seven days following an injury, but varies depending upon the location and type of fracture. Most often a splint is used in the interim. Successful casting requires three things: proper materials, proper positioning, and selection and application of the appropriate type of cast. Fractures likely to require casting acutely include those with the following characteristics [1]: Reduction was required Two adjacent bone are involved (eg, fracture of radius and ulna) Segmental fractures Spiral fractures Fracture dislocations Fractures where muscles exert strong forces that may cause displacement Some fractures, such as those of the proximal humerus, are not amenable to casting, while others that should be casted, such as certain ankle fractures in children, are often not [1]. Nevertheless, casting remains the treatment of choice for most nonoperative fractures. Materials Fiberglass and plaster of Paris are the two most common types of fracture "tape" used for casting; each has relative advantages and disadvantages. Fiberglass is lighter, stronger, more breathable, and sets more quickly than plaster (picture 1) [3]. According to a laboratory study using a prosthesis model of limb swelling, fiberglass applied with a stretch-relax technique accommodates swelling better and causes less skin surface pressure than plaster [4]. (See

'Application of cast' below.) Fiberglass is a skin irritant, and clinicians should wear gloves when applying a fiberglass cast. Plaster molds more uniformly than fiberglass, which is an advantage in maintaining fracture reduction. Plaster also sets more slowly, making it easier for less experienced clinicians to apply it correctly. However, plaster tape is messier, heavier, and breaks down more easily than fiberglass tape, and it can produce a significant exothermic reaction while it sets. For these reasons, many clinicians prefer fiberglass for most casting applications. Protection of the skin from the overlying fiberglass or plaster is essential to prevent breakdown and related complications. Skin protection begins with the application of a stockinette, the first layer of any cast, followed by adequate but not excessive amounts of padding (picture 2 and picture 3). Both stockinette and cast padding have traditionally been made of cotton, but synthetic materials are becoming available. Several forms of synthetic stockinette and padding materials are designed to allow for the cast to become wet. It is important to use the appropriate amount of padding, especially over bony prominences, which are susceptible to pressure and skin breakdown from the cast. Extra padding is often needed in such areas (eg, lateral epicondyle, ulnar styloid, medial and lateral malleoli). However, care must be taken to avoid excess padding, especially around the fracture site, as this can lead to a loose cast that provides inadequate immobilization [1]. Type of cast When selecting the appropriate cast, the clinician must determine which joints to include and how far the cast should extend. Maximal immobilization is achieved with casts that include the joints proximal and distal to the fracture site. This is important in treating any unstable fracture, such as a reduced distal radius fracture. Whenever possible, the entire length of the fractured bone should be included in the cast [1]. The accompanying table describes several common casts and the fractures for which they are best suited (table 1). Application of cast The key steps in the application of a fiberglass cast are outlined below. For illustrative purposes, a short arm cast with a thumb spica is described, but the basic steps apply to all fiberglass casts. Select the appropriate padding and width for casting (fiberglass or plaster) tape. Two-inch (5 cm) tape is generally good for the hand, three-inch (7.5 cm) for the forearm, and four-inch (10 cm) for the lower extremity and upper arm (picture 3). The stockinette width is also based on the size of the limb being casted (picture 2). Cutting the stockinette slightly longer than the cast allows for the edges to be rolled back prior to the application of the final layer of casting material, providing a smooth edge to the cast. First apply the stockinette (picture 4). Next, apply the padding (eg, Webril) by rolling it onto the extremity in a distal to proximal direction; each layer should overlap the preceding layer by approximately 50 percent (picture 5). Additional Webril or padding should be placed over bony

prominences. In general, about two layers of padding are adequate for the upper extremity; three to four layers are used for the lower extremity. Once the padding is in place and the limb properly positioned, moisten the casting tape (picture 1). Cool water should be used for fiberglass tape. "Tepid" or room temperature water works well for plaster. Warmer water will shorten the set time, but may cause skin burns. Roll the casting tape over the extremity moving distal to proximal (picture 6). When applying fiberglass tape, stretch and then relax the tape during application to reduce the skin surface pressure [4]. Special cuts can be used to help navigate smaller areas, such as around the thumb. This helps to prevent bulking of the cast and can improve comfort. After the first few layers of casting tape are applied, the cast should be molded if necessary (picture 7). The goal of molding is to maintain alignment of an unstable fracture. An oval or elliptical shaped cast is better suited for maintaining fracture alignment than a perfectly cylindrical cast [2]. Improper molding or any sharp indentations in the cast can cause severe complications, such as pressure sores and skin ulcers. Clinicians with little experience casting should limit molding to gently compressing the cast into an elliptical shape at the area of the fracture. The palms and heels of the hands should be used; avoid using fingers [2]. This approach provides adequate molding while decreasing the risk for skin breakdown. Practitioners with experience casting may use a three-point molding technique. The first point of compression is directly over the apex of the fracture with the force directed opposite the direction in which the fracture is most likely to displace. The two remaining pressure points lie on the opposite side of the bone at either side of the apex. Force is maintained at these three sites until the cast has set. As described above, the palms and heels of the hand should be used to apply pressure and use of the fingers avoided. Fold the ends of the stockinette over the set casting tape and apply the final layer of tape (picture 8). In all, two layers of fiberglass tape are usually sufficient for short arm casts, three layers for long arm casts and non-weightbearing short leg casts, and four layers for weightbearing short leg casts (picture 9). Inspect the cast to ensure that there are no rough or sharp edges protruding and that sensation and blood flow distal to the cast end are intact. Written instructions explaining proper cast care should be provided to the patient. (See 'Information for patients' below.) An alternative technique for applying a fiberglass cast may be useful for less experienced clinicians [5]. This approach differs in that the casting tape is not moistened before it is applied. Rather, the fiberglass tape is applied directly out of its packaging and a water based gel, such as KY Jelly, is

spread evenly over each roll after it is applied. This technique allows for a longer set time and permits adjustments to be made to casting position after each roll is placed. The same steps described above are used when applying a short leg cast. A few special considerations for the short leg cast include: Cut the stockinette on the dorsal side just over and parallel to the ankle (ie, tibiotalar) joint to prevent wrinkling, which can lead to skin irritation. Four inch padding is needed for lower extremity casts; apply extra padding over bony prominences (eg, malleoli, fibular head). Maintain the ankle in 90 degrees of dorsiflexion (ie, neutral position) to create a position of function (especially for weightbearing casts) and to prevent flexion contractures. Leave all five toes visible to allow for neurovascular assessment. Positioning Casts should place the affected joints in their position of function whenever possible (table 1). The wrist and hand are usually placed in a grasping position. The ankle and elbow are usually casted at 90 degrees. Sometimes these general rules are adjusted to obtain a better outcome. As an example, the wrist may be placed in a more neutral to slightly flexed position to help maintain reduction when treating a distal radius fracture. Changes in fracture position can occur during cast application despite an optimal reduction and excellent casting technique with proper molding. Therefore, we suggest obtaining x-rays immediately following cast application for any unstable fracture or any fracture that required reduction prior to casting. Complications Potential complications associated with fractures are reviewed separately. Complications associated with casting are discussed below. (See "General principles of fracture management: Early and late complications".) While immobilization in a cast is important for maintaining reductions and provides the basis for fracture healing, it can lead to joint stiffness, muscle atrophy, and disuse syndromes, and increases the risk for thrombosis. Casts that are applied too tightly or that become too tight due to soft tissue swelling can cause vascular compromise. Skin breakdown, compression neuropathy, and acute compartment syndrome can also occur. Any patient in a cast who complains of pain, burning, tingling, or numbness should be evaluated immediately because of these potentially severe complications. (See "Approach to the diagnosis and therapy of lower extremity deep vein thrombosis" and "Acute compartment syndrome of the extremities" and "Overview of lower extremity peripheral nerve syndromes" and "Overview of upper extremity peripheral nerve syndromes" and "Acute arterial occlusion of the lower extremities (acute limb ischemia)" and "Pressure ulcers: Epidemiology, pathogenesis, clinical manifestations, and staging".)

Depending upon the age and comorbidities of the patient, even routine casting may result in prolonged losses of motion and muscular strength that require treatment with physical or occupational therapy [1]. Other casting complications include skin burns, which are more likely if plaster is used with hot water [6]. FOLLOW-UP VISITS Overview After the initial cast is applied and fracture alignment is confirmed, the next essential step is to ensure adequate and timely follow-up. The interval between visits depends on the nature of the fracture, the type of cast, and any concerns there may be about patient compliance. Even in the rare instance where no follow-up is required (eg, healthy adult with a minor fibular avulsion fracture treated in a pneumatic splint), the clinician should provide clear instructions about whom to call for signs of skin breakdown, infection, neurovascular compromise, or for worsening or persistent pain. Unstable fractures or post-reduction fractures require more frequent reassessment, sometimes as often as twice a week initially to ensure that correct fracture alignment is maintained [1]. As a general rule, lower extremity casting involves longer immobilization times to maximize stability and strength. Upper extremity casting generally involves shorter periods of immobilization in order to retain range of motion [1]. Follow-up visits for stable fractures Initial follow-up after casting of a stable fracture is usually scheduled three to seven days later, with instructions to call or return earlier for pain, swelling, or other acute symptoms. Subsequent follow-up visits vary according to the patient and cast but are usually scheduled about every two to three weeks. At each follow-up visit, the cast should be carefully checked for signs of wear and proper fit. The cast should be replaced if it is too loose, too tight, or excessively worn. Most weightbearing plaster casts maintain their integrity for two to three weeks, while non-weightbearing plaster casts last about four weeks. Fiberglass casts typically remain intact for two weeks longer than their plaster counterparts. These time frames are approximations and depend on patient activity, weight, and age. The casts of children and active adults should be checked more frequently to ensure proper immobilization [1]. Follow-up visits are ideal venues for teaching appropriate rehabilitative exercises and ensuring compliance with activity restrictions. Follow-up visits for unstable fractures Unstable fractures are prone to loss of reduction or malalignment while being treated in a cast. The proper times to recheck alignment depend on the fracture type and the age of the patient. As an example, pediatric both-bone forearm fractures are among the most unstable fractures. Since children heal at a relatively rapid rate and only small amounts of angulation are acceptable

in the forearm, midshaft fractures of both the radius and ulna require radiographic follow-up two times per week until healing has occurred. Conversely, angulated distal radius fractures in adults need only be reassessed once every 7 to 10 days post-injury. If excessive angulation is noted at that time, the bone can be re-manipulated because fracture fragments remain relatively mobile in adults. Radiographs to reassess fracture alignment in unstable fractures while they are healing should be obtained in the cast. Radiographs taken in traditional plaster or fiberglass generally provide sufficient clarity to judge the alignment of long bone fractures, although evidence of healing may be obscured. Several types of casting tape offer superior radiolucency (eg, 3M Scotchcast, MPACT OCL Polylite), which may be helpful when evaluating unstable fractures *7+. Orthopedic referral Between visits, patients can develop complications that warrant orthopedic evaluation. As an example, unacceptable changes in fracture angulation may appear on follow-up radiographs and orthopedic consultation should be obtained in such cases to determine the best treatment. Any new deficit in neurovascular function requires immediate evaluation by an orthopedic surgeon. FRACTURE HEALING The goal of casting is to provide a sufficient period of immobilization such that the fracture heals properly. However, prolonged immobilization increases the risk of complications. An accurate assessment of fracture healing is essential to striking a balance between these twin considerations. Unfortunately, determining when clinical union has occurred can be problematic. Understanding the basic biology of bone healing and then relying on a combination of clinical and radiographic factors offers the best estimation of when a fracture is adequately healed [8]. (See 'Complications' above.) Biology of fracture healing The biology of bone healing is discussed separately. (See "General principles of fracture management: Bone healing and fracture description", section on 'Biology of bone healing'.) Clinical assessment of fracture healing Proper assessment of clinical union is essential to optimize fracture healing and to prevent complications from excessive immobilization. Biomechanical studies of fracture stiffness show that clinical union typically occurs one to two weeks before evidence of radiographic union [9,10]. Additionally, radiologic parameters of fracture healing have poor interobserver correlation [10], and tend to underestimate healing progress when compared with clinical [9], biomechanical [9-11], and histologic [11] measures. Given the limitations of radiographic parameters, typical clinical practice is to schedule a follow-up visit around the time of expected healing, usually around four to six weeks post-injury. The cast is removed and clinical features of healing are assessed. These can include the ability to bear weight [12], no tenderness to palpation at the fracture site [1], and stability and absence of pain with manual stress testing [8]. If the fracture demonstrates clinical healing and appropriate signs of healing are seen on radiographs, then the fracture is deemed healed and the patient begins

rehabilitation. If the fracture does not demonstrate signs of clinical healing or appropriate healing is not seen on x-rays, a cast is reapplied. Alternatively, a functional splint or brace, which allows for some gentle range of motion exercises to be done out of the device, can be used. The fracture is then reassessed in two weeks. Fracture healing depends on multiple biologic and biomechanical factors and some patients may need to be recasted several times. If a fracture is not clinically healed four weeks after the expected time of healing, additional confirmation of bony healing should be sought through advanced imaging (MRI or CT scanning) and consultation with an orthopedic surgeon. As a general rule, lower extremity casting involves longer immobilization times to maximize stability and strength. Upper extremity casting generally involves shorter periods of immobilization in order to retain range of motion [1]. ADJUNCTIVE THERAPY FOR FRACTURE HEALING Overview and basic measures A number of adjunctive therapies are used to aid fracture healing. While a detailed discussion is beyond the scope of this review, a brief description of some of the more commonly mentioned therapies is included here. Pain management for patients with fractures and the effects of specific drugs on fracture healing are discussed separately. (See "General principles of acute fracture management", section on 'Pain management' and "General principles of fracture management: Early and late complications", section on 'Nonunion and malunion'.) For all patients with fractures, regardless of the site, it is important to ensure good nutrition, including adequate intake of vitamin D and calcium, to maximize fracture healing. Although evidence exists to support the role of vitamin D in fracture prevention, there is no high quality evidence to support the use of supplemental vitamin D for the treatment of acute fractures. However, prescribing supplemental vitamin D in this setting seems a reasonable practice given the prevalence of vitamin D deficiency in the general population and the low potential for side effects or toxicity. A daily dose of 1000 international units during fracture healing is reasonable. (See "Vitamin supplementation in disease prevention", section on 'Vitamin D' and "Overview of vitamin D".) Cigarette smoking and excessive alcohol use impairs fracture healing. Patients should be encouraged to stop smoking and limit alcohol consumption. (See "General principles of fracture management: Early and late complications", section on 'Nonunion and malunion'.) Pharmacologic adjuncts Systemic therapies A wide range of pharmacologic treatments to accelerate fracture healing are being studied. Such treatments include growth hormone (GH), bone morphogenetic proteins (BMP), parathyroid hormone (PTH), platelet-derived growth factor, and bisphosphonates. Most studies are preliminary and the appropriate role for these therapies in the treatment of acute fractures remains speculative [13-16].

Local therapies Locally injected or applied treatments to improve fracture healing, such as platelet-rich therapies, are under investigation. However, studies are preliminary and the appropriate role for such therapies in the treatment of acute fractures remains speculative [17]. Prevention of complex regional pain syndrome Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy, is a complex disorder of the extremities characterized by localized pain, swelling, limited range of motion, vasomotor instability, skin changes, and bone demineralization. Fractures, with or without a nerve injury, are a common inciting event. Measures to prevent this debilitating syndrome, including supplemental vitamin C, are discussed separately. (See "Prevention and management of complex regional pain syndrome in adults" and "Etiology, clinical manifestations, and diagnosis of complex regional pain syndrome in adults".) Nonpharmacologic adjuncts Several nonpharmacologic interventions have been used to aid fracture healing. Among these are electromagnetic stimulation (bone stimulators) and ultrasound. Electromagnetic stimulation is used most often to hasten healing after internal fixation or bone grafting has been performed for fractures that failed to heal with standard treatment (ie, nonunions) [18]. Although the United States Food and Drug Administration has approved low intensity pulsed ultrasound for the treatment of acute fractures and nonunions, debate continues about the quality of the evidence supporting this intervention [19]. A systematic review confirmed that the available studies are heterogeneous, but concluded that the evidence does not support routine use of ultrasound for fracture healing [20]. Large controlled trials are needed to determine the value of these treatments.