In open fractures, non-operative management is primarily used for temporary stabilization as a bridge to surgical treatment or referral. In low-resource settings, where surgical options are limited, non-operative techniques for open fracture treatment can provide functional outcomes. Although they should be regarded as substandard management.

Casting

Plaster casts serve three key purposes in fracture care:

1 To immobilize bone fragments in the correct position,

2 To protect the injured limb while healing occurs, and

3 To relieve pain and improve patient comfort.

However, plaster casts are not without risks. They can:

• Obstruct circulation, leading to ischemia
• Cause pressure sores 
• Be heavy and uncomfortable for the patient
• Contribute to joint stiffness if immobilization is prolonged
• Lead to disuse osteoporosis if left on too long
• In humid/moisty environments, like tropical settings, casts will often not last for long and are therefore not the preferred treatment method 

Plaster can be applied in two main forms:

Slabs
Slabs are best used as a temporary solution, especially:

• When swelling is expected
• When the patient is being referred to another hospital

Slabs allow for limb expansion during the acute phase and reduce the risk of circulatory compromise. They are typically secured with crepe bandages, which adapt as swelling in- or decreases. 

Slabs may not provide adequate immobilization for unstable fractures and are prone to break at joints like the elbow or knee.

Circular casts
A circular cast is a full, circumferential plaster application that completely surrounds the limb. It provides more rigid and stable immobilization than a slab.

Caution - When applied too early, before swelling has resolved, circular casts can increase the risk of compartment syndrome and compromise circulation.

In the case of a cast being to tight, the cast must be split or replaced to prevent severe complications. To split the cast, use a scalpel or plaster knife while the cast is still soft. Cut along one side, through the full thickness of the cast. When the cast has already hardened it is best to use a plaster saw.

Remember - as swelling decreases, the cast may become loose and ineffective.

Indications for casting in open fractures

Casting in open fractures has a limited role and should be reserved for carefully selected cases:

1 Gustilo-Anderson Type I open fractures in which the fracture type, if it was a closed fracture, allows casting as treatment.

2 As temporary stabilisation, awaiting for definitive surgical treatment, or referral to a center where external or internal fixation is possible.

3 In situations where neither surgical treatment nor referral is possible. However, this strategy should be recognised as suboptimal, and referral should be pursued as soon as it becomes available.

The general sequence when treating open fractures definitively with a cast is as follows:

1 Debridement

2 Reduction

3 Application of a backslab

Maintain the backslab until acute swelling has subsided and the risk of compartment syndrome has decreased, typically after approximately 72 hours. Once swelling has resolved, convert to a circular cast. Create an adequate window to allow ongoing wound inspection and care.

Throughout treatment, frequently reassess the wound, neurovascular status, and the fit and integrity of the cast.

Cast technique per fracture location

How to apply a circular cast with a window

A window in a circular cast is created in open fractures to allow wound inspection and dressing changes.

Example of a circular cast with a window to allow adequate access to the wound.

Materials Needed

• Stockinette (if available)
• 2 rolls 100 mm padding or cut a roll of ordinary cotton wool into smaller rolls 10 cm wide
• 4–6 POP rolls (100 mm wide) or  8–9 POP rolls for above-knee cast
• Bucket with cold or lukewarm water
• Examination couch/table
• Floor covering, aprons
• Cast saw or scissors

Procedural steps

1 Examine the Limb

• Look for - Wounds, blistering, bone sticking out and check the neurovascular status (circulation, sensation, movement).
• Radiographs - Determine the fracture location and nature of fracture.
• Debridement and washout - Ensure debridement and washout of open wounds before casting them.

Wounds in open fractures are not always directly over the fracture site. In high-energy trauma, bone fragments may be markedly displaced, breach the skin, and then return to a less displaced position before clinical presentation.

2 Positioning and Reduction

Manual closed reduction - Manual closed reduction is performed externally, without surgical exposure of the fracture. In most cases, it involves a combination of traction to restore length and carefully applied counterpressure to correct angulation and rotation.

3 Padding

• Cover the wound - Cover the wound with some layers of gauzes exceeding the wound edges slightly before casting. This will mark the location where to create the window later.
• 50% overlap - Start distally with 50% overlap between layers
• Extra padding - Add extra padding on bony points: malleoli, fibular head, patella
• Positioning - Avoid placing the joint at extreme range of motion, as this can lead to pressure necrosis of joint cartilage and cause arthritis later

4 POP Application

• 50% overlap - Overlap 50% between layers
• Layering - Apply 8–10 layers
• Below-knee - Stop 2 cm below fibular head
• Above-knee - Include knee with 15–20° flexion

5 Plaster Moulding

• Moulding - Mould the cast with flat hands, not fingers
• Pressure - Apply continuous pressure until the cast hardens.
• Hardening - 5 minutes for shaping, 24–48 hours until the cast fully sets

6 Creating the Window

• Window - Once set, cut a tangential window directly over wound site using a saw or plaster scissors
• Keep the removed cast segment - Windows may allow soft tissues to swell and herniate, impairing wound healing. Therefore, replace the cut-out window and secure it with a bandage. Remove it only during wound care.
• Keep it dry - Prevent to wet the cast when performing wound care.
• Replace the cast - Windows weaken the cast, therefore put a new stronger cast without a window once soft tissues have fully healed.

7 Check

• Cleaning - Clean exposed skin.
• Neurovascular reassessment - Check circulation, sensation and movement.
• Radiograph - Consider a follow-up radiograph after reduction and casting.

8 Patiënt Education

Inform patient about red flag symptoms:

• Pain and swelling - Increasing pain and swelling
• Sensation - Numbness, pulselessness
• Color - Color change in digits
• Smell - Unusual smell
• Fever - Elevated body temperature, chills, shivering or sweating

Further instructions:

Traction

Traction is a method of fracture alignment and stabilization using a longitudinal pulling force to achieve ligamentotaxis. By applying this force, limb length and alignment are restored, pain is reduced, and soft tissues are protected. In general, traction is used as a temporary method to stabilize unstable fractures (e.g during transport), particularly in the presence of significant soft tissue injury or when definitive surgery is delayed.

Definitive treatment – In selected cases, traction may give reasonable outcome when used as definitive treatment, particularly in resource-limited settings where internal and/or external fixation is unavailable, unsafe, or not feasible, and referral is not an option. Always bear in mind this treatment strategy is suboptimal.

Caution – Prolonged immobilisation during traction is associated with several risks (e.g. pressure sores, joint stiffness, venous thromboembolism, pneumonia, muscle wasting, urinary tract infections, and constipation). Early physiotherapy, regular repositioning, skin inspection, and appropriate thromboprophylaxis are essential to reduce these risks.

Traction can be applied using different techniques and at various anatomical sites:

External traction

External traction is primarily used in pediatric fracture patients, as skeletal pin placement carries a higher risk of pin-related complications. External traction is less suitable in situations where:

1 High traction forces are required

2 Prolonged traction is needed

3 An open fracture, blistering, or fragile skin prevent skin or cast traction.

Cast traction

Cast traction serves as a temporary form of traction in which a lower-leg POP cast is used as a grip to apply a longitudinal pulling force along the limb.

Cast traction is particularly used in children

Applying cast traction

1 Apply a circular lower leg cast and allow it to fully harden first.

2 Position a stick on the posterior aspect at the level of the Achilles tendon or under the foot sole and secure it by rolling an additional layer of POP around both the stick and the cast.

3 When fully hardened, attach the traction setup to the stick. Weight maximum 10% bodyweight. 

Skeletal traction

Skeletal traction is a method that uses a 'through the bone' inserted pin as a grip to apply longitudinal traction. Compared with external traction, it allows

1 Higher traction forces

2 Can be maintained for longer periods

3 In some set ups it can allow adjacent joint movement and decreases the risk of joint stiffness

General principles

For all forms of skeletal traction, the following general principles and requirements apply:

Exercise

Femoral Traction

Distal femoral traction is indicated when traction through the tibia is not suitable due to knee pathology or associated tibial fractures. By placing the traction pin in the distal femoral condyles, effective alignment can be achieved while avoiding traction through the knee or lower leg.

1 Pin placement

• Incision - Make a small stab incision over the chosen site.
• Dissect - Bluntly dissect with artery forceps down to bone to protect soft tissues.
• Pin insertion - Insert a 4 mm Steinmann pin transversely through the femoral condyles, +- 1–2 cm above the superior pole of the patella.
• Pin direction - Ensure the pin is perpendicular to the long axis of the femur.
• Femoral artery - Go anterior to midline to avoid femoral artery.
• Radiograph - Preferably confirm postoperative pin position and limb alignment on a lateral X-ray.

Caution - Avoid joint capsule penetration and neurovascular structures during pin insertion.

2 Traction Setup

• Pin ends - Use a tension bow, stirrup, or Thomas pin mounts to attach the pin
• Robe attachment - Attach the rope and pass it through the traction bed frame pulley or direct rope over a smooth surface.
• Foot elevation - Elevate the foot end of the bed by ~20–25 cm for counter-traction.
• Tension bow - Ensure tension bow does not rest on the tibia (pad if needed).

Tibial Traction

Proximal tibial traction, also known as Perkins traction, provides skeletal traction for unstable femoral fractures and allows knee-joint movement. Femoral fractures that benefit from proximal tibial traction are listed below.

1 Pin Insertion

• Incision - Make a small stab incision over the chosen site.
• Dissect - Bluntly dissect with artery forceps down to bone to protect soft tissues.
• Pin insertion - Insert a Steinmann or Denham pin.
• Avoid thermal injury - Manual insertion with a T-handle, or low-speed power drill with irrigation to avoid thermal injury
• Pin direction - Ensure the pin is perpendicular to the limb axis and passes through both cortices.
• Pin depth - Leave at least 3–4 cm of pin exposed on each side for traction attachments.

Avoid the common peroneal nerve laterally and posterior tibial vessels medially

2 Traction Setup

• Pin ends - Use a tension bow, stirrup, or Thomas pin mounts to attach the pin
• Robe attachment - Attach the rope and pass it through the traction bed frame pulley or direct rope over a smooth surface.
• Foot elevation - Elevate the foot end of the bed by ~20–25 cm for counter-traction.
• Tension bow - Ensure tension bow does not rest on the tibia (pad if needed).

Tibial skeletal traction setup

Calcaneal Traction

Calcaneal pin traction is used for temporary stabilization of certain unstable tibial fractures.

1 Pin placement

• Marking - Mark the desired entry and exit site of the pin. Use a vertical reference line drawn from the lateral malleolus to the plantar edge of the heel, divide this line in 3 parts, and mark the pin site on the junction of middle and distal third.
• Incision - Stab the skin at the insertion side medially.
• Dissect - Spread with an artery forceps till reaching the bone, avoiding the posterior tibial neurovascular bundle. Preferably place a tissue protector.
• Pin insertion - Insert a sharp, sterile 4 mm Steinmann or Denham pin from medial to lateral through the posterior calcaneus.
• Pin end - Protect the sharp pin end for example with an empty glass medication bottle

Caution – Placing the pin too posteriorly may result in a dorsiflexion deformity.

2 Traction set-up 

• Elevation - Elevate the foot end of the bed by ~25 cm. This provides counter-traction and prevents the patient from sliding downward.

Do not place padding under the heel. Instead, support the lower leg behind the ankle and under the calf so the heel is suspended and free from mattress contact.

Pressure sores - Check the skin over the heel and malleoli regularly for pressure sores.