Adequate analgesia and muscle relaxation are critical for success.
a. Hematoma block—aspirate hematoma and place 10 cm3 of lidocaine at fracture site.
i. May be less reliable than other methods.
ii. Fast and easy.
b. Intravenous sedation:
i. Versed (0.5–1 mg q 3 minutes up to 5 mg).
ii. Morphine (0.1 mg/kg).
iii. Demerol (1–2 mg/kg up to 150 mg).
iv. Beware of pulmonary complications with deep conscious sedation—consider anesthesia service assistance if there is concern.
v. Physician should be credentialed for “conscious sedation.”
vi. Pulse oximeter and careful monitoring are recommended.
c. Bier block—It results in superior pain relief, greater relaxation, and less premedication is needed.
i. Double tourniquet is inflated on proximal arm and venous system is filled with local.
ii. Lidocaine is preferred for fast onset.
iii. Volume = 40 cm3.
iv. Adults: 2–3 mg/kg, children: 1.5 mg/kg.
v If tourniquet is deflated after < 40 minutes then deflate for 3 seconds and reinflate for 3 minutes—repeat twice.
vi. Watch closely for cardiac and neurologic side effects, especially in the elderly patients.
2. Reduction is accomplished by some form of traction and force directed against the deformity to correct the length, alignment, and rotation of the bone and it may be specific for fracture location and pattern.
a. Reduction may require reversal of mechanism of injury, especially in children with intact periosteum.
b. When the bone breaks because of bending, the soft tissues disrupt on the convex side and remain intact on the concave side.
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
