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. 2022 Feb 24;7(1):28060. doi: 10.51894/001c.28060

Closed Fracture Treatment in Adults, When is it Still Relevant?

Matthew Coon 1, Marek Denisiuk 1, Derrek Woodbury 2, Benjamin Best 3, Rahul Vaidya 2
PMCID: PMC8873430  PMID: 35291707

Abstract

INTRODUCTION

Fracture treatment has been documented since the times of ancient Egyptian and Greek civilization, with fracture reduction techniques and the apparatus for immobilization developed over three millennia. Over the last 150 years, aseptic technique, anesthesia, antibiotics, and internal implants have changed how orthopedic specialists approach fracture care. More recently, there has been an increased promotion in the medical literature to evaluate the clinical outcomes of nonsurgical treatment of common upper and lower extremity closed fractures.

METHODS

In this paper, the authors review the history of closed extremity fracture treatments, outline contemporary studies regarding treatments of non-displaced fractures, and discuss the recent literature that has informed orthopedic surgeon-patient decision-making discussions regarding closed fracture management.

CONCLUSIONS

Based on the results of this literature review, orthopedic providers should consider the preferable outcomes associated with nonoperative fracture management such as lower infection rates, the possibility of rapid functional improvements and lower healthcare costs. Nonoperative methods for closed fractures can sometimes be more safely delivered even with more difficult fractures. This may be of particular benefit to patients with higher surgical risks, minimizing exposure to treatments that are not only more invasive and expensive, but that can impose greater postoperative risks.

Keywords: review, non-operative, closed treatment, trauma

INTRODUCTION

Through the 20th century, the nonsurgical treatment of closed fractures (i.e., when bone is broken, but skin intact) have been the standard of care.1 The earliest documentation of fracture care was in the Egyptian “Edwin Smith” papyrus, circa 1600 b.c.1 Egypt was also the site of the earliest examples of active fracture care (e.g., splints) on an unhealed femur fracture, dated around 300 b.c.2

At approximately 400 b.c., Hippocrates wrote three books “Fractures,” “Articulations, and”Instruments of Reduction” for fracture management.3 He noted the five following principles of care: antisepsis, reduction, traction, bandaging, and splinting.3 In developing nations, “bonesetters” in Asia, Africa, and in native populations of North and South America have typically been non-medically trained practitioners treating fractures and reducing joint dislocations with skills developed using an apprentice model. Although lay bonesetters have not been accepted by many mainstream medical communities,4 present-day bonesetters in developing nations may still have their services preferred over modern medical techniques.5

Early methods to stabilize fractures recorded by Hippocrates included linen splints stiffened with gum and plaster; bandages suffused with resins, gums, and waxes.3 Bandages with lime and egg white have also been recorded by Arabic physicians.6,7 The use of plaster was first described in 1798 by British surgeons who had observed Persians using gypsum. In 1852, the Dutch military surgeon Matthysen devised a method to coat and infuse cotton bandages with gypsum to make the first casting bandages.8 During the 1930s, the addition of binders (e.g., starches, gums, and dextrins) made commercial bandage preparation more feasible, although it wasn’t until the mid-1940s that commercial plaster bandages became commonly used.9

Immobilization treatments of closed fractures (e.g., slings, splints, casts traction avoidance of weight bearing) are still the most widely used method of fracture management.10 Tables 1 and 2 depict the modes of immobilization, when to start range of motion, and when to return to normal function based on medical textbooks 11,12 as well as the senior authors’ (i.e., BB, DW, RV) clinical experiences. Due to subjective nature of considering closed fracture management options, it is recommended that each case be taken individually and tailored to the patient’s particular fracture pattern and morphology. Although these fracture patterns may initially be treated by an emergency medicine physician or other primary care provider, in the United States, these fractures are, as a standard of care, referred for fracture management to an orthopedic surgeon.

Table 1. Upper Extremity Closed Fracture Management Options.

Fracture Treatment Start Movement Activity Return to function
Clavicle and Acromioclavicular Joint Sling Two-Three weeks Two-Three weeks passive or active ROM* Six-10 weeks
Proximal Humerus Sling or airplane splint Two-Three weeks Two-Three weeks gentle ROM or active assisted six weeks active resistance Six-10 weeks
Humerus shaft Coaptation splint, sling and swath
Two-Three weeks and switch to Sarmiento		 Two-Three weeks pendulum / isometric DC brace when active abduction painless and no fracture movement 12 weeks
Distal humerus, olecranon, coronoid, radial head 90-degree post mold cast or sling One-Two weeks One-Two weeks One-Two weeks passive ROM, active ROM Four-Six weeks when painless
Strengthening at six weeks when painless		 Six-12 weeks
Radius / Ulna Splint 90 deg
Switch to above elbow cast when comfortable		 Four-Six weeks Four-Six weeks ROM for elbow Six-12 weeks
Distal radius / Carpus Volar splint
Switch to cast		 Four-Six weeks ROM active / Resistance exercises six weeks Six-12 weeks
Metacarpals, Ulnar Two Ulnar gutter splint Three-Four weeks ROM active / resistance exercises four weeks Six-12 weeks
Metacarpals, Radial Two Volar splint switch to cast Three-Four weeks ROM active / resistance exercises four weeks Six-12 weeks
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* ROM – range of motion

Table 2. Lower Extremity Closed Fracture Management Options.

Fracture Treatment Start Movement Activity Return to function
Pelvic fracture Protected weight bearing Right away Weight bearing when tolerated Two-Six weeks Six-12 weeks
Acetabular fracture No weight bearing on effected side Right away Weight bearing Six-12 weeks 12 weeks
Femur fractures, proximal and shaft, should not be treated nonoperatively
Tibia fracture proximal Above knee cast six weeks
Hinged cast brace Six-10 weeks		 Six weeks Active ROM, weight bearing 10-12 weeks 12-20 weeks
Tibia shaft fracture Above knee cast Four-Six weeks
Sarmiento PTB* cast
Four-12 weeks		 Six weeks partial weight bearing Active ROM, weight bearing 10-12 weeks 16-20 weeks
Lateral malleolar ankle fractures Cast or fracture boot ROM right away Partial to full weight bearing as tolerated 12 weeks
Bimalleolar or equivalent fracture Cast above knee two-four weeks
Below knee up to six weeks		 Four-Six weeks Weight bearing Six weeks 12 weeks
Talus fracture Cast or boot Four-Six weeks Weight bearing 12 weeks for neck or body fracture 16-20 weeks
Calcaneus fracture Protective boot ROM right away Weight bearing Eight-12 weeks 16-24 weeks
Foot fractures Protective boot or cast ROM four weeks Weight bearing Four-Six weeks Six-10 weeks
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* PTB – patellar tendon bearing

The following sections of this literature review will focus on the most common types of upper and lower extremity displaced fractures. Hand and foot fractures will not be reviewed. Classic and current studies will be discussed to provide readers a historical perspective and comprehensive review of the current state of non-operative treatment of displaced fractures in modern orthopedics.

Displaced Upper Extremity Fracture Treatments

Clavicle Fractures

Fractures of the clavicle account for up to 10% of adult fractures and up to 80% of these fractures occur in the middle third of the shaft.13 Non-displaced or minimally displaced fractures generally heal well with a sling for two to three weeks followed by physical therapy with a typical return to normal function in six to 10 weeks. Displaced clavicle fractures with higher-risk characteristics including 100% displacement, shortening greater than two cm., or Z-type (i.e., characterized by vertical positioning of a segmental fragment) fracture pattern have been reported to have a nonunion rate of up to 15% with nonoperative treatment (Table 3).14

Table 3. Clavicle Fracture Outcomes: Operative vs Nonoperative Treatment.

Investigators Sample Size Findings Miscellaneous
Amer et al., 2020 954 displaced (100%) or >2cm of shortening Lower nonunion and symptomatic malunion with operative fixation; No difference in Constant or DASH* scores Meta-analysis; operative vs nonoperative
Zlowodzki et al., 2005 2144 (97% midshaft) Overall nonunion rate of 5.9% for nonoperative treatment; nonunion rate for displaced fractures is 15.1% Systematic Review of 22 articles
Woltz et al., 2017 160 displaced midshaft No difference in Constant and DASH scores; significantly higher nonunion rate in nonoperative group Multicenter, RCT**; ORIF*** vs nonoperative treatment
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** Randomized Controlled Trial

*** Open Reduction Internal Fixation

A 2017 Level I randomized controlled trial by Woltz et. al. compared open reduction internal fixation (ORIF) to nonoperative treatment for displaced midshaft clavicular fractures in adults. This group identified a higher rate of nonunion in the nonoperative group of 23.1% compared with 2.4% in the ORIF group. Despite a high union rate, operative treatment was also associated with a secondary surgery rate of 27.4% and peri-incisional anesthesia of 19%.15

Scapula Fractures

Scapula fractures can be divided based on the energy (i.e., amount of force causing the fracture) involved and fracture location. Although traditionally considered high energy injuries (e.g. automobile accident), low energy injuries may occur in the elderly. In both groups, nonoperative management consists of sling immobilization with progression to physical therapy at two weeks. Consideration for ORIF should be made in cases involving glenohumeral instability, intra-articular involvement, and displacement.16–18

A 2018 systematic review of all scapular fracture types reported satisfactory results in 90.4% (N = 629) of nonoperatively treated patients and 93.7% (N = 512) of operatively treated patients.19 Nonoperative treatment for displaced scapular neck fractures > 10 mm demonstrated only 15.7% patient satisfaction, versus 94.7% satisfaction with displacement < 10 mm. Scapular body fractures treated nonoperatively resulted in excellent outcomes in 100% of patients. For coracoid (i.e., short, bony projection off scapula) fractures, nonoperative treatment led to excellent outcomes and is equivalent to surgical intervention. However, fractures of the scapular neck extending into the body resulted in satisfactory outcomes in only 50% of nonoperatively treated patients with surgery demonstrating superior outcomes.19

Proximal Humeral Fractures

Since the 1950s, little has changed in the closed treatment of proximal humerus fractures. Nonoperative management typically consists of two weeks of sling application with a progressive physical therapy regimen for non-displaced fractures. Although the introduction of locked plating may have improved operative fixation of displaced fractures, several studies fail to show significant relative improvements in clinical outcomes (Table 4). Several systematic reviews and randomized studies 20–24 conducted between 2011 and 2019 comparing ORIF versus nonoperative treatment for three- and four-part fractures found no significant differences in Constant scores (i.e., four-variable scoring system used to assess the function of the shoulder) or other clinical outcomes at one year.

Table 4. Proximal Humerus Fracture Outcomes: Operative vs Nonoperative Treatments.

Investigators Sample Size Findings Miscellaneous
Mao et al., 2014 287 3- or 4-part No difference in Constant, DASH, or total complication events Meta-analysis; modest sample size
Fjalestad et al., 2012 48 displaced 3- or 4-part No difference in functional outcome at 1-year follow up RCT ORIF vs conservative
Lopiz et al., 2019 59 displaced 3- and 4- part No difference in any patient-reported outcomes except VAS score at 12 months RCT RSA vs conservative
Olerud et al., 2011 60 displaced 3- part  Indicate an advantage in functional outcome and HRQoL***** in favor of the locking plate RCT ORIF vs conservative; 2 year outcome; 30% cost of additional surgery for surgical cohort
Rangan et al., 2015 250 displaced surgical neck No difference in patient-reported outcomes over 2 years RCT multicenter; internal fixation/replacement vs conservative
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* DASH - Disabilities of the Arm, Shoulder and Hand

** RCT – randomized controlled trial

*** ORIF – open reduction internal fixation

**** VAS – visual analog scale

***** HRQoL - Health-related quality of life

Humeral Diaphysis Fractures

Displaced humeral shaft fractures has been traditionally treated in nonoperative manner during substantial investigations confirming low nonunion rates and good outcomes.25 However, like many other displaced fracture patterns, a modern trend towards ORIF has been generating interest.26 Management typically involves initial treatment with a well-molded U-slab or coaptation splint with conversion to functional bracing at two weeks.12

The humerus easily tolerates 30 degrees of varus angulation and 20 degrees of anterior angulation which results in a functional range of motion of the upper extremity and normal cosmesis.27 Most patients in this and other studies have demonstrated good to excellent functional outcomes.28–30 The location of the fracture within the bone determines successful healing with union rates of up to 88% for middle and distal third shaft fractures and 76% for proximal third shaft fractures.31 However, certain humeral fracture characteristics (e.g., spiral and oblique fracture patterns) should guide orthopedic surgeons towards ORIF.32,33

Forearm Fractures

Isolated ulna fractures can generally be treated with immobilization as long as there is some overlap of the fracture ends with proper alignment.34 Although stable, open ulnar fractures from both firearm and more severe non-firearm mechanisms may be treated conservatively if there are minimal osseous displacement and soft-tissue trauma, more severe open injuries are better managed with surgical ORIF.35,36

Distal Radius Fractures

Many distal radius fractures can be reduced to the anatomic position of 12 mm. radial height, 11 degrees volar tilt, and 23 degrees radial inclination.37 Unfortunately, closed reductions may not retain their position over a two-to-three-week period until initial healing is obtained. This has been attributed to advanced age or the deforming forces caused by the surrounding musculature, resulting in longitudinal and angular deformities and fracture characteristics such as initial displacement and shortening.38

In 1989, Lafontaine described fracture characteristics that predicted a loss of reduction in cast immobilization if three or more of the following criteria were present: dorsal tilt >20 degrees, dorsal comminution, intra-articular fracture, associated ulnar fracture, and age over 60 years.39 The definition of fracture instability remains varied throughout the literature.40,41 The American Academy of Orthopedic Surgery Clinical practice guidelines advise operative fixation for fractures with post-reduction radial shortening of greater than 3.0 mm, dorsal tilt > 10 degrees, or intra-articular displacement or step-off greater than 2.0 mm.42 Comparative studies of operative versus nonoperative treatment of displaced distal radius fractures in elderly patients have shown better radiologic results, however, some studies have shown no advantage in functional outcomes (Table 5).43–45

Table 5. Distal Radius Fracture Outcomes: Operative vs Nonoperative Treatment.

Investigators Sample Size Findings Miscellaneous
Egol et al., 2010 90 displaced, unstable Minor limitations in ROM of wrist and diminished grip strength with nonoperative care Case-control study; Surgery vs conservative
Toon et al., 2017 60 closed, intra-articular No difference in overall function at 12 months Comparative study; ORIF vs conservative; Vast difference in treatment costs
Ochen et al., 2020 2254 No improvement in DASH scores in patients >60 yo Meta-analysis; 8 RCTs and 15 observational studies
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Treatment of Displaced Lower Extremity Fractures

Pelvic Ring Fractures

Low energy pelvic ring injuries tend to heal with time when treated conservatively.46 Indications for ORIF include high energy injuries, to prevent death from hemorrhage, deformity in displaced injuries, and to allow early mobility. Hemorrhage traditionally has been controlled with a pelvic binder, angiography, pelvic packing, and addressing non-pelvic causes of bleeding.12

For patients who are unable to sit or choose non-operative intervention, bed rest is recommended for one to two weeks followed by a gradual increase in activity over the next two to three months. Patients with displaced pelvic ring injuries greater than 1.0 cm who are treated conservatively tend to have a higher malunion rate,47 experience greater pain at longer-term follow-up, and have more difficulty ambulating compared to ORIF patients.47 In 2014, Gaski et. al. assessed the functional outcomes of potentially unstable lateral compression fractures, demonstrating that nonoperative treatment yielded acceptable functional and perceived health status outcomes in this population.48

Femoral Shaft Fractures

Nonoperative treatment of femoral shaft fractures occurs in some developing nations, as well as in patients who are not amenable to operative treatment.49 One form of nonoperative treatment of femoral shaft fractures includes Perkins traction,50 which allows movement of the knee during traction. The results of Perkins traction are reported to have a nonunion rate of 10%, malunion rate of five percent, shortening > 2.5 cm, and acceptable range of motion. The average length of hospital stay is eight weeks, with a mean healing time approximately 10 weeks, and return to function about 16 weeks.50–52

Intramedullary nailing of femur fractures results in a 98% union rate, a low rate of leg length discrepancy (i.e., less than five percent; 20% in comminuted/splintered fractures), and rotational malalignment (i.e., as low as five percent). As a result, operative fixation of femur fractures with intramedullary nailing has become one of the great success stories of the 20th century for American orthopedic surgeons.53

Tibial Shaft Fractures

Traditionally, tibial shaft fractures have been treated with traction (i.e., use of ropes, pulleys and weights to regain the original length of injured bone), casting, functional bracing, external fixation, plating, and intramedullary nailing.54 The treatment of choice for isolated, displaced closed tibia fractures has recently migrated to intramedullary nailing, secondary to high rates of union and low rates of malunion.55 Despite this shift, closed treatment remains a potentially viable option.56,57 Patients are typically placed in above knee long leg casts and switched to functional braces after three to five weeks.58 In Sarmiento’s 1989 series of 780 tibial fractures, the nonunion rate was 2.5%, shortening of < 10mm occurred in 90% of patients, and an acceptable angular deformity of < 10 degrees was generally attained.58

However, studies comparing intramedullary nailing to nonoperative treatment have demonstrated a decreased time to union, increased union rate, decreased malunion rate, early weight bearing, improved function, and earlier return to work and sports with surgery.55 During a 2020 retrospective study by Swat et. al., factors predictive of successful nonoperative treatment include initial coronal and sagittal translation, shortening, fracture morphology and location, body mass index, and smoking status.59

In a comparative study of casting versus intramedullary nailing of unilateral, displaced, isolated closed fractures of the tibial shaft, time to healing was shorter (i.e., 16 weeks vs. 18 weeks) and nonunion rates were reduced (two vs 10%) in the ORIF group. Functional outcomes were superior in the operative group.55

Ankle Fractures

Ankle fractures are articular injuries of the mortise joint accounting for 9% of all adult fractures.60 Ankle fractures were historically treated with closed reduction and above knee casting for two to three weeks followed by below knee casting for three to four weeks or longer depending on healing potential.61 Currently, nonoperative treatment of ankle fractures includes a short leg cast, splint, or walking boot. Indications for closed treatment include rotationally stable fracture patterns where the syndesmosis remains intact, talus is reduced, and when an acceptable reduction is achieved. Conservative management of ankle fractures is a difficult task, frequently failing secondary to a loss of reduction requiring later surgical interventions (Table 6).

Table 6. Ankle Fracture Outcomes: Operative vs Nonoperative Treatment.

Investigators Sample Size Findings Miscellaneous
Elgayar et al., 2019 951 closed Risk of malunion, nonunion, and loss of reduction were greater with nonoperative care Systematic Review; 5 RCTs surgical vs conservative intervention
Javed et al., 2020 1153 displaced or unstable No difference in ankle function scores at 6 or 12 months; surgery had lower rates of early tx failure, malunion, and nonunion Systematic review and Meta-analysis from 7 trials; surgical vs conservative management
Donken et al., 2012 292 Insufficient evidence to conclude whether surgical or conservative treatment produces superior long-term outcomes Cochrane Database systemic review; surgical vs conservative intervention; 3 RCTs and 1 quasi-RCT
Petrisor et al., 2006 1394 displaced No significant differences in adverse events or function for operative vs non-operative management Meta-analysis of 25 RCTs surgical vs conservative intervention
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Stress radiographs should be obtained to evaluate for ankle instability secondary to disruption of the syndesmosis or deltoid ligament.62 Patient age should not be a determinant when deciding on operative versus nonoperative treatment in the absence of systemic comorbidities such as cardiovascular disease, pulmonary disease, and poorly controlled diabetes with end organ damage.63 2019 systematic review and meta-analysis found that conservative treatment of ankle fractures led to a lower rate of infection, decreased need for further surgery, and improved cost-effectiveness.57 Despite these findings, closed reduction often failed, and a large percentage of patients were transitioned to the operative group. The rates of malunion (15%) and nonunion (10%) were also higher in the nonoperative group.64

Overall, there have been study findings that ORIF of ankle fractures versus non-operative interventions has provided equivalent functional outcomes.65 However, ORIF has also resulted in an anatomic reduction, fewer malunions, and fewer nonunions. Due to the small number of studies, large time range, and heterogeneity between study protocols, no definitive conclusions could be made by the authors.66,67

CONCLUSIONS

Based on this literature review, the authors conclude that nonsurgical treatments for a wide variety of closed extremity fractures can be frequently applied with minimal patient risks. It remains important for orthopedic surgeons to review nonsurgical alternatives for fractures with patients during the decision-making discussions. Less risky and less costly nonoperative methods can sometimes be utilized even with more difficult fractures, particularly with patients possessing higher surgical risks.

Conflicts of Interest

The authors deny any conflicts of interest.

Funding Statement

The authors did not receive support from any organization.

References

  1. Breasted James Henry., editor. Facsimile plates and line for line hieroglyphic transliteration. The Univ. of Chicago Press; Chicago, Ill: OCLC: 256713119. [Google Scholar]
  2. THE MOST ANCIENT SPLINTS. Smith G. E. Mar 28;1908 British Medical Journal. 1:732–736.2. doi: 10.1136/bmj.1.2465.732. PMID: 20763747 PMCID: PMC2436247. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Hippocrates. Adams Francis. The genuine works of Hippocrates. Kessinger Publishing; Whitefish, Mont: OCLC: 213416619. [Google Scholar]
  4. The instruments of the bonesetter. Phillips S.-A., Biant L. C. Jan;2011 The Journal of Bone and Joint Surgery. British volume. 93-B(1):115–119. doi: 10.1302/0301-620X.93B1.25628. [DOI] [PubMed] [Google Scholar]
  5. Fracture treatment by bonesetters in central Ghana: patients explain their choices and experiences. Ariës Marcel J. H., Joosten Hanneke, Wegdam Harry H. J., van der Geest Sjaak. Apr;2007 Tropical medicine & international health: TM & IH. 12(4):564–574. doi: 10.1111/j.1365-3156.2007.01822.x. PMID: 17445148. [DOI] [PubMed] [Google Scholar]
  6. The history of plaster-of-paris in the treatment of fractures. Monro J. K. Oct;1935 British Journal of Surgery. 23(90):257–266. doi: 10.1002/bjs.1800239005. [DOI] [Google Scholar]
  7. M. S. Spink and G. L. Lewis (ed. and tr.): Albucasis: On surgery and instruments. (Publications of the Wellcome Institute of the History of Medicine, New Series, Vol. xii.) xv, 850 pp. London: Wellcome Institute of the History of Medicine, 1973. £15. Iskandar A. Z. Jun;1975 Bulletin of the School of Oriental and African Studies. 38:440–442. doi: 10.1017/S0041977X00142685. [DOI] [Google Scholar]
  8. Treatment of broken legs before and after the introduction of gypsum. Austin R. T. Mar;1983 Injury. 14(5):389–394. doi: 10.1016/0020-1383(83)90089-x. PMID: 6347885. [DOI] [PubMed] [Google Scholar]
  9. Short history of plaster-of-Paris cast immobilization. Callahan D. J., Harris B. J. Apr;1986 Minnesota Medicine. 69(4):195–196. PMID: 3523193. [PubMed] [Google Scholar]
  10. Nonoperative fracture treatment in the modern era. Court-Brown Charles M., Aitken Stuart, Hamilton Thomas W., Rennie Louise, Caesar Ben. Sep;2010 The Journal of Trauma. 69(3):699–707. doi: 10.1097/TA.0b013e3181b57ace. PMID: 20065878. [DOI] [PubMed] [Google Scholar]
  11. Rockwood Charles A., Green David P., Bucholz Robert W., editors. Rockwood and Green's fractures in adults. Wolters Kluwer Health/Lippincott Williams & Wilkins; Philadelphia, PA: OCLC: ocn444336477. [Google Scholar]
  12. Browner Bruce D. Skeletal trauma: basic science, management, and reconstruction. Elsevier; St. Louis, MO: [Google Scholar]
  13. Operative Versus Nonoperative Outcomes of Middle-Third Clavicle Fractures: A Systematic Review and Meta-Analysis. Amer Kamil, Smith Brendan, Thomson Jennifer E., Congiusta Dominick, Reilly Mark C., Sirkin Michael S., Adams Mark R. Jan;2020 Journal of Orthopaedic Trauma. 34(1):e6–e13. doi: 10.1097/BOT.0000000000001602. PMID: 31851115. [DOI] [PubMed] [Google Scholar]
  14. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group. Zlowodzki Michael, Zelle Boris A., Cole Peter A., Jeray Kyle, McKee Michael D., Evidence-Based Orthopaedic Trauma Working Group Aug;2005 Journal of Orthopaedic Trauma. 19(7):504–507. doi: 10.1097/01.bot.0000172287.44278.ef. PMID: 16056089. [DOI] [PubMed] [Google Scholar]
  15. Plate Fixation Compared with Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter Randomized Controlled Trial. Woltz Sarah, Stegeman Sylvia A., Krijnen Pieta, van Dijkman Bart A., van Thiel Tom P. H., Schep Niels W. L., de Rijcke Piet A. R., Frölke Jan Paul M., Schipper Inger B. Jan 18;2017 The Journal of Bone and Joint Surgery. American Volume. 99(2):106–112. doi: 10.2106/JBJS.15.01394. PMID: 28099300. [DOI] [PubMed] [Google Scholar]
  16. Multiple trauma and scapula fractures: so what? Veysi Veysi T., Mittal Rajnish, Agarwal Sanjeev, Dosani Anis, Giannoudis Peter V. Dec;2003 The Journal of Trauma. 55(6):1145–1147. doi: 10.1097/01.TA.0000044499.76736.9D. PMID: 14676662. [DOI] [PubMed] [Google Scholar]
  17. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. Zlowodzki Michael, Bhandari Mohit, Zelle Boris A., Kregor Philip J., Cole Peter A. Mar;2006 Journal of Orthopaedic Trauma. 20(3):230–233. doi: 10.1097/00005131-200603000-00013. PMID: 16648708. [DOI] [PubMed] [Google Scholar]
  18. Outcome of glenoid neck fractures. Pace Alistair M., Stuart Ranald, Brownlow Harry. Dec;2005 Journal of Shoulder and Elbow Surgery. 14(6):585–590. doi: 10.1016/j.jse.2005.03.004. PMID: 16337524. [DOI] [PubMed] [Google Scholar]
  19. A systematic review of management of scapular fractures. Kannan Sudhir, Singh Harvinder Pal, Pandey Radhakant. Dec;2018 Acta Orthopaedica Belgica. 84(4):497–508. PMID: 30879456. [PubMed] [Google Scholar]
  20. Operative versus nonoperative treatment in complex proximal humeral fractures. Mao Zhi, Zhang Lihai, Zhang Licheng, Zeng Xiantao, Chen Shuo, Liu Daohong, Zhou Zhirui, Tang Peifu. May;2014 Orthopedics. 37(5):e410–419. doi: 10.3928/01477447-20140430-50. PMID: 24810816. [DOI] [PubMed] [Google Scholar]
  21. Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial. Fjalestad Tore, Hole Margrethe Ø, Hovden Inger Anette Hynås, Blücher Judith, Strømsøe Knut. Feb;2012 Journal of Orthopaedic Trauma. 26(2):98–106. doi: 10.1097/BOT.0b013e31821c2e15. PMID: 21804410. [DOI] [PubMed] [Google Scholar]
  22. Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective randomized controlled trial. Lopiz Yaiza, Alcobía-Díaz Borja, Galán-Olleros María, García-Fernández Carlos, Picado Amanda López, Marco Fernando. Dec;2019 Journal of Shoulder and Elbow Surgery. 28(12):2259–2271. doi: 10.1016/j.jse.2019.06.024. PMID: 31500986. [DOI] [PubMed] [Google Scholar]
  23. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. Olerud Per, Ahrengart Leif, Ponzer Sari, Saving Jenny, Tidermark Jan. Jul;2011 Journal of Shoulder and Elbow Surgery. 20(5):747–755. doi: 10.1016/j.jse.2010.12.018. PMID: 21435907. [DOI] [PubMed] [Google Scholar]
  24. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. Rangan Amar, Handoll Helen, Brealey Stephen, Jefferson Laura, Keding Ada, Martin Belen Corbacho, Goodchild Lorna, Chuang Ling-Hsiang, Hewitt Catherine, Torgerson David, PROFHER Trial Collaborators Mar 10;2015 JAMA. 313(10):1037–1047. doi: 10.1001/jama.2015.1629. PMID: 25756440. [DOI] [PubMed] [Google Scholar]
  25. Humeral shaft fractures: a review. Walker Matt, Palumbo Brian, Badman Brian, Brooks Jordan, Van Gelderen Jeffrey, Mighell Mark. Jul;2011 Journal of Shoulder and Elbow Surgery. 20(5):833–844. doi: 10.1016/j.jse.2010.11.030. PMID: 21393016. [DOI] [PubMed] [Google Scholar]
  26. Operative vs. Nonoperative Treatment of Isolated Humeral Shaft Fractures: A Prospective Cohort Study. Cannada Lisa K., Nelson Lauren, Tornetta Paul, Hymes Robert, Jones Clifford B., Obremskey William, Carroll Eben, Mullis Brian, Tucker Michael, Teague David, Marcantonio Andrew, Ostrum Robert, Core Michael Del, Israel Heidi. 2021Journal of Surgical Orthopaedic Advances. 30(2):67–72. PMID: 34181519. [PubMed] [Google Scholar]
  27. FRACTURES OF THE SHAFT OF THE HUMERUS. Klenerman L. Feb;1966 The Journal of Bone and Joint Surgery. British volume. 48-B(1):105–111. doi: 10.1302/0301-620X.48B1.105. [DOI] [PubMed] [Google Scholar]
  28. Functional bracing for the treatment of fractures of the humeral diaphysis. Sarmiento A., Zagorski J. B., Zych G. A., Latta L. L., Capps C. A. Apr;2000 The Journal of Bone and Joint Surgery. American Volume. 82(4):478–486. doi: 10.2106/00004623-200004000-00003. PMID: 10761938. [DOI] [PubMed] [Google Scholar]
  29. Diaphyseal fractures of the humerus. Treatment with prefabricated braces. Zagorski J. B., Latta L. L., Zych G. A., Finnieston A. R. Apr;1988 The Journal of Bone and Joint Surgery. American Volume. 70(4):607–610. PMID: 3356728. [PubMed] [Google Scholar]
  30. Outcome after closed functional treatment of humeral shaft fractures. Ekholm Radford, Tidermark Jan, Törnkvist Hans, Adami Johanna, Ponzer Sari. Oct;2006 Journal of Orthopaedic Trauma. 20(9):591–596. doi: 10.1097/01.bot.0000246466.01287.04. PMID: 17088659. [DOI] [PubMed] [Google Scholar]
  31. Operative versus non-operative treatment of humeral shaft fractures: A systematic review. Sargeant Harry William, Farrow Luke, Barker Scott, Kumar Kapil. Aug;2020 Shoulder & Elbow. 12(4):229–242. doi: 10.1177/1758573218825477. PMID: 32788928 PMCID: PMC7400715. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Nonunion after functional brace treatment of diaphyseal humerus fractures. Ring David, Chin Kingsley, Taghinia Amir H., Jupiter Jesse B. May;2007 The Journal of Trauma. 62(5):1157–1158. doi: 10.1097/01.ta.0000222719.52619.2c. PMID: 17495717. [DOI] [PubMed] [Google Scholar]
  33. Fracture Site Mobility at 6 Weeks After Humeral Shaft Fracture Predicts Nonunion Without Surgery. Driesman Adam S., Fisher Nina, Karia Raj, Konda Sanjit, Egol Kenneth A. Dec;2017 Journal of Orthopaedic Trauma. 31(12):657–662. doi: 10.1097/BOT.0000000000000960. PMID: 28708781. [DOI] [PubMed] [Google Scholar]
  34. Gebuhr P., Hölmich P., Orsnes T., Soelberg M., Krasheninnikoff M., Kjersgaard A. G. Sep;1992 Isolated ulnar shaft fractures. Comparison of treatment by a functional brace and long-arm cast. 74(5):757–759. doi: 10.1302/0301-620X.74B5.1527129. PMID: 1527129. [DOI] [PubMed] [Google Scholar]
  35. Joint and long-bone gunshot injuries. Dougherty Paul J., Vaidya Rahul, Silverton Craig D., Bartlett Craig S., Najibi Soheil. 2010Instructional Course Lectures. 59:465–479. PMID: 20415399. [PubMed] [Google Scholar]
  36. Management of adult diaphyseal both-bone forearm fractures. Schulte Leah M., Meals Clifton G., Neviaser Robert J. Jul;2014 The Journal of the American Academy of Orthopaedic Surgeons. 22(7):437–446. doi: 10.5435/JAAOS-22-07-437. PMID: 24966250. [DOI] [PubMed] [Google Scholar]
  37. Essential Radiographic Evaluation for Distal Radius Fractures. Medoff Robert J. Aug;2005 Hand Clinics. 21(3):279–288. doi: 10.1016/j.hcl.2005.02.008. [DOI] [PubMed] [Google Scholar]
  38. Early and late displacement of fractures of the distal radius. The prediction of instability. Altissimi M., Mancini G. B., Azzarà A., Ciaffoloni E. Apr;1994 International Orthopaedics. 18(2):61–65. doi: 10.1007/BF02484412. PMID: 8039959. [DOI] [PubMed] [Google Scholar]
  39. Stability assessment of distal radius fractures. Lafontaine M., Hardy D., Delince P. Jul;1989 Injury. 20(4):208–210. doi: 10.1016/0020-1383(89)90113-7. PMID: 2592094. [DOI] [PubMed] [Google Scholar]
  40. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. Walenkamp Monique M. J., Vos Lara M., Strackee Simon D., Goslings J. Carel, Schep Niels W. L. Nov;2015 Journal of Wrist Surgery. 4(4):307–316. doi: 10.1055/s-0035-1556860. PMID: 26649263 PMCID: PMC4626227. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Predictors of unstable distal radius fractures: a systematic review and meta-analysis. Walenkamp M. M. J., Aydin S., Mulders M. a. M., Goslings J. C., Schep N. W. L. Jun;2016 The Journal of Hand Surgery, European Volume. 41(5):501–515. doi: 10.1177/1753193415604795. PMID: 26420817. [DOI] [PubMed] [Google Scholar]
  42. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on: The Treatment of Distal Radius Fractures. Lichtman David M., Bindra Randipsingh R., Boyer Martin I., Putnam Matthew D., Ring David, Slutsky David J., Taras John S., Watters William C., Goldberg Michael J., Keith Michael, Turkelson Charles M., Wies Janet L., Haralson Robert H., Boyer Kevin M., Hitchcock Kristin, Raymond Laura. Apr;2011 JBJS. 93(8):775–778. doi: 10.2106/JBJS.938ebo. [DOI] [PubMed] [Google Scholar]
  43. Distal Radial Fractures in the Elderly: Operative Compared with Nonoperative Treatment: Egol K A, Walsh M, Romo-Cardoso S, Dorsky Seth, Paksima N. Aug;2010 J Bone Joint Surg Am. 92(9):1851–1857. doi: 10.2106/JBJS.I.00968. [DOI] [PubMed] [Google Scholar]
  44. Outcomes and financial implications of intra-articular distal radius fractures: a comparative study of open reduction internal fixation (ORIF) with volar locking plates versus nonoperative management. Toon Dong Hao, Premchand Rex Antony Xavier, Sim Jane, Vaikunthan Rajaratnam. Sep;2017 Journal of Orthopaedics and Traumatology: Official Journal of the Italian Society of Orthopaedics and Traumatology. 18(3):229–234. doi: 10.1007/s10195-016-0441-8. PMID: 28155059 PMCID: PMC5585087. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults: A Systematic Review and Meta-analysis. Ochen Yassine, Peek Jesse, van der Velde Detlef, Beeres Frank J. P., van Heijl Mark, Groenwold Rolf H. H., Houwert R. Marijn, Heng Marilyn. 2020JAMA network open. 3(4):e203497. doi: 10.1001/jamanetworkopen.2020.3497. PMID: 32324239 PMCID: PMC7180423. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Pelvic Insufficiency Fractures. O'Connor Timothy J., Cole Peter A. Dec;2014 Geriatric Orthopaedic Surgery & Rehabilitation. 5(4):178–190. doi: 10.1177/2151458514548895. PMID: 26246940 PMCID: PMC4252160. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Pelvic ring disruptions: treatment modalities and analysis of outcomes. Papakostidis C., Kanakaris N. K., Kontakis G., Giannoudis P. V. Apr;2009 International Orthopaedics. 33(2):329–338. doi: 10.1007/s00264-008-0555-6. PMID: 18461325 PMCID: PMC2899093. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Nonoperative treatment of intermediate severity lateral compression type 1 pelvic ring injuries with minimally displaced complete sacral fracture. Gaski Greg E., Manson Theodore T., Castillo Renan C., Slobogean Gerard P., OʼToole Robert V. Dec;2014 Journal of Orthopaedic Trauma. 28(12):674–680. doi: 10.1097/BOT.0000000000000130. PMID: 24740110. [DOI] [PubMed] [Google Scholar]
  49. Outcome of non-operative management of femoral shaft fractures in children. Akinyoola A. L., Orekha O. O., Taiwo F. O., Odunsi A. O. Apr;2011 African journal of paediatric surgery: AJPS. 8(1):34–39. doi: 10.4103/0189-6725.78666. PMID: 21478584. [DOI] [PubMed] [Google Scholar]
  50. Rest and movement. Perkins George. Nov;1953 The Journal of Bone and Joint Surgery. British volume. 35-B(4):521–539. doi: 10.1302/0301-620x.35b4.521. doi: 10.1302/0301-620x.35b4.521. [DOI] [PubMed] [Google Scholar]
  51. [The conservative treatment of femur fractures by Perkins traction. Management in adverse situations] Mandrella B. Oct;2002 Der Unfallchirurg. 105(10):923–931. doi: 10.1007/s00113-002-0467-7. PMID: 12376898. [DOI] [PubMed] [Google Scholar]
  52. Perkins traction for adult femoral shaft fractures: a report on 53 patients in Sierra Leone. Gosselin Richard, Lavaly Daniel. Oct;2007 International Orthopaedics. 31(5):697–702. doi: 10.1007/s00264-006-0233-5. PMID: 17043864 PMCID: PMC2266653. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Intramedullary nailing of femoral shaft fractures: current concepts. Ricci William M., Gallagher Bethany, Haidukewych George J. May;2009 The Journal of the American Academy of Orthopaedic Surgeons. 17(5):296–305. doi: 10.5435/00124635-200905000-00004. PMID: 19411641. [DOI] [PubMed] [Google Scholar]
  54. Closed tibial shaft fractures: management and treatment complications. A review of the prospective literature. Coles C. P., Gross M. Aug;2000 Canadian Journal of Surgery. Journal Canadien De Chirurgie. 43(4):256–262. PMID: 10948685 PMCID: PMC3695213. [PMC free article] [PubMed] [Google Scholar]
  55. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients. Bone L. B., Sucato D., Stegemann P. M., Rohrbacher B. J. Sep;1997 The Journal of Bone and Joint Surgery. American Volume. 79(9):1336–1341. doi: 10.2106/00004623-199709000-00007. PMID: 9314395. [DOI] [PubMed] [Google Scholar]
  56. Factors influencing the outcome of closed tibial fractures treated with functional bracing. Sarmiento A., Sharpe F. E., Ebramzadeh E., Normand P., Shankwiler J. Jun;1995 Clinical Orthopaedics and Related Research. (315):8–24. PMID: 7634690. [PubMed]
  57. Fractures of the middle third of the tibia treated with a functional brace. Sarmiento Augusto, Latta Loren L. Dec;2008 Clinical Orthopaedics and Related Research. 466(12):3108–3115. doi: 10.1007/s11999-008-0438-6. PMID: 18719973 PMCID: PMC2628234. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Tibial shaft fractures treated with functional braces. Experience with 780 fractures. Sarmiento A., Gersten L. M., Sobol P. A., Shankwiler J. A., Vangsness C. T. Aug;1989 The Journal of Bone and Joint Surgery. British Volume. 71(4):602–609. doi: 10.1302/0301-620X.71B4.2768307. PMID: 2768307. [DOI] [PubMed] [Google Scholar]
  59. Modern treatment of tibial shaft fractures: Is there a role today for closed treatment? Swart Eric, Lasceski Chad, Latario Luke, Jo Jacob, Nguyen Uyen-Sa D. T. 2020Injury. doi: 10.1016/j.injury.2020.10.018. PMID: 33046252 PMCID: PMC7534823. [DOI] [PMC free article] [PubMed]
  60. Epidemiology of adult fractures: A review. Court-Brown Charles M., Caesar Ben. Aug;2006 Injury. 37(8):691–697. doi: 10.1016/j.injury.2006.04.130. PMID: 16814787. [DOI] [PubMed] [Google Scholar]
  61. Malleolar fractures: nonoperative versus operative treatment. A controlled study. Bauer M., Bergström B., Hemborg A., Sandegård J. Oct;1985 Clinical Orthopaedics and Related Research. (199):17–27. PMID: 3930121. [PubMed]
  62. Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements. Park Samuel S., Kubiak Erik N., Egol Kenneth A., Kummer Fred, Koval Kenneth J. Jan;2006 Journal of Orthopaedic Trauma. 20(1):11–18. doi: 10.1097/01.bot.0000189591.40267.09. PMID: 16424804. [DOI] [PubMed] [Google Scholar]
  63. Management of ankle fractures in the elderly. Rammelt Stefan. May;2016 EFORT open reviews. 1(5):239–246. doi: 10.1302/2058-5241.1.000023. PMID: 28461954 PMCID: PMC5367590. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Surgical versus conservative management of ankle fractures in adults: A systematic review and meta-analysis. Javed Omar A., Javed Qasim A., Ukoumunne Obioha C., Di Mascio Livio. Oct;2020 Foot and Ankle Surgery: Official Journal of the European Society of Foot and Ankle Surgeons. 26(7):723–735. doi: 10.1016/j.fas.2019.09.008. PMID: 31818542. [DOI] [PubMed] [Google Scholar]
  65. A Systematic Review Investigating the Effectiveness of Surgical Versus Conservative Management of Unstable Ankle Fractures in Adults. Elgayar Lugman, Arnall Frances, Barrie Jim. Sep;2019 The Journal of Foot and Ankle Surgery: Official Publication of the American College of Foot and Ankle Surgeons. 58(5):933–937. doi: 10.1053/j.jfas.2018.12.017. PMID: 31474404. [DOI] [PubMed] [Google Scholar]
  66. Surgical versus conservative interventions for treating ankle fractures in adults. Donken Christian C. M. A., Al-Khateeb Hesham, Verhofstad Michael H. J., van Laarhoven Cornelis J. H. M. Aug 15;2012 The Cochrane Database of Systematic Reviews. (8):CD008470. doi: 10.1002/14651858.CD008470.pub2. PMID: 22895975. [DOI] [PMC free article] [PubMed]
  67. Management of displaced ankle fractures. Petrisor Brad A., Poolman Rudolf, Koval Kenneth, Tornetta Paul III, Bhandari Mohit. Aug;2006 Journal of Orthopaedic Trauma. 20(7):515–518. doi: 10.1097/00005131-200608000-00012. doi: 10.1097/00005131-200608000-00012. [DOI] [PubMed] [Google Scholar]

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