General principles of definitive fracture management
- Anthony Beutler, MD
Anthony Beutler, MD
- Associate Professor of Family Medicine
- Uniformed Services University
- Stephen Titus, MD
Stephen Titus, MD
- Assistant Professor of Family Medicine
- Fort Belvoir Community Hospital Family Medicine Residency
- Uniformed Services University of the Health Sciences
- Section Editors
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics; Sports-Related Injuries
- Professor of Family Medicine
- Oregon Health & Science University
- Chad A Asplund, MD, FACSM, MPH
Chad A Asplund, MD, FACSM, MPH
- Associate Professor of Health and Kinesiology
- Director of Athletic Medicine
- Head Team Physician
- Georgia Southern University
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
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".)
Overview — Casting is standard treatment for many closed, nondisplaced, or reduced fractures . Casts provide a stable, protected environment in which the external, periosteal callus can form and normal bone healing can proceed .
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. Nevertheless, several fracture types are best managed with acute casting. In such cases, the casts are either maintained in a single piece or converted into functional splints by creating “valves” in the cast (ie, two incisions along the entire length, thereby dividing the cast into two pieces) that can accommodate some soft tissue swelling.
Fractures likely to require casting acutely include those with the following characteristics :
- Eiff MP, Hatch RL, Calmbach WL. General principles of fracture care. In: Fracture Management for Primary Care, 2nd ed, WB Saunders, Philadelphia 2003. p.4.
- Connolly JF, Mendes M, Browner BD. Principles of closed management of common fractures. In: Skeletal Trauma, Browner BD, Jupiter JB, Levine AM, et al. (Eds), WB Saunders, Philadelphia 1992. p.215.
- Mihalko WM, Beaudoin AJ, Krause WR. Mechanical properties and material characteristics of orthopaedic casting material. J Orthop Trauma 1989; 3:57.
- Davids JR, Frick SL, Skewes E, Blackhurst DW. Skin surface pressure beneath an above-the-knee cast: plaster casts compared with fiberglass casts. J Bone Joint Surg Am 1997; 79:565.
- Smith GD, Hart RG, Tsai TM. Fiberglass cast application. Am J Emerg Med 2005; 23:347.
- Harkess JW, Ramsey WC. Principles of fractures and dislocations. In: Rockwood and Greens's Fractures in Adults, 4th ed, Rockwood CA, Green DP (Eds), Lippincott-Raven, Philadelphia 1996. p.48.
- Puddy AC, Sunkin JA, Aden JK, et al. Cast saw burns: evaluation of simple techniques for reducing the risk of thermal injury. J Pediatr Orthop 2014; 34:e63.
- McDowell M, Nguyen S, Schlechter J. A Comparison of Various Contemporary Methods to Prevent a Wet Cast. J Bone Joint Surg Am 2014; 96:e99.
- Mazzola TJ. Splinting and casting. In: Sports Medicine Resource Manual, 1st ed, Seidenberg P, Beutler AL (Eds), Saunders, Philadelphia 2007. p.152.
- McGowan HJ. General principles of fracture management. In: Sports Medicine Resource Manual, 1st ed, Seidenberg P, Beutler AL (Eds), Saunders, Philadelphia 2007. p.147.
- Claes L, Grass R, Schmickal T, et al. Monitoring and healing analysis of 100 tibial shaft fractures. Langenbecks Arch Surg 2002; 387:146.
- McClelland D, Thomas PB, Bancroft G, Moorcraft CI. Fracture healing assessment comparing stiffness measurements using radiographs. Clin Orthop Relat Res 2007; 457:214.
- Blokhuis TJ, de Bruine JH, Bramer JA, et al. The reliability of plain radiography in experimental fracture healing. Skeletal Radiol 2001; 30:151.
- Joslin CC, Eastaugh-Waring SJ, Hardy JR, Cunningham JL. Weight bearing after tibial fracture as a guide to healing. Clin Biomech (Bristol, Avon) 2008; 23:329.
- Ettehad H, Mirbolook A, Mohammadi F, et al. Changes in the serum level of vitamin d during healing of tibial and femoral shaft fractures. Trauma Mon 2014; 19:e10946.
- Garrison KR, Shemilt I, Donell S, et al. Bone morphogenetic protein (BMP) for fracture healing in adults. Cochrane Database Syst Rev 2010; :CD006950.
- Ellegaard M, Jørgensen NR, Schwarz P. Parathyroid hormone and bone healing. Calcif Tissue Int 2010; 87:1.
- Graham S, Leonidou A, Lester M, et al. Investigating the role of PDGF as a potential drug therapy in bone formation and fracture healing. Expert Opin Investig Drugs 2009; 18:1633.
- Tran GT, Pagkalos J, Tsiridis E, et al. Growth hormone: does it have a therapeutic role in fracture healing? Expert Opin Investig Drugs 2009; 18:887.
- Griffin XL, Wallace D, Parsons N, Costa ML. Platelet rich therapies for long bone healing in adults. Cochrane Database Syst Rev 2012; :CD009496.
- Griffin XL, Costa ML, Parsons N, Smith N. Electromagnetic field stimulation for treating delayed union or non-union of long bone fractures in adults. Cochrane Database Syst Rev 2011; :CD008471.
- Saleh A, Hegde VV, Potty AG, et al. Management strategy for symptomatic bisphosphonate-associated incomplete atypical femoral fractures. HSS J 2012; 8:103.
- Hannemann PF, Mommers EH, Schots JP, et al. The effects of low-intensity pulsed ultrasound and pulsed electromagnetic fields bone growth stimulation in acute fractures: a systematic review and meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg 2014; 134:1093.
- Adie S, Harris IA, Naylor JM, et al. Pulsed electromagnetic field stimulation for acute tibial shaft fractures: a multicenter, double-blind, randomized trial. J Bone Joint Surg Am 2011; 93:1569.
- Busse JW, Kaur J, Mollon B, et al. Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials. BMJ 2009; 338:b351.
- Griffin XL, Parsons N, Costa ML, Metcalfe D. Ultrasound and shockwave therapy for acute fractures in adults. Cochrane Database Syst Rev 2014; :CD008579.
- TRUST Investigators writing group, Busse JW, Bhandari M, et al. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ 2016; 355:i5351.
- Schandelmaier S, Kaushal A, Lytvyn L, et al. Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials. BMJ 2017; 356:j656.
- Type of cast
- Application of cast
- Cast removal
- Keeping casts dry
- FOLLOW-UP VISITS
- Follow-up visits for stable fractures
- Follow-up visits for unstable fractures
- Orthopedic referral
- FRACTURE HEALING
- Biology of fracture healing
- Clinical assessment of fracture healing
- ADJUNCTIVE THERAPY FOR FRACTURE HEALING
- Overview and basic measures
- Pharmacologic adjuncts
- - Systemic therapies
- - Local therapies
- Prevention of complex regional pain syndrome
- Nonpharmacologic adjuncts
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS