Conservative treatment of fractures

Last updated: June 27, 2023

Summarytoggle arrow icon

Conservative management of fractures comprises closed reduction, immobilization, and supportive care. Conservative management is the definitive treatment for closed, stable, and/or simple fractures; it is generally contraindicated in open, unstable, and/or complex fractures. The closed reduction technique and type of immobilization device used are determined based on the individual patient and injury. Splinting is preferred over casting for the initial immobilization of most fractures because it better accommodates secondary swelling and is therefore associated with a lower risk of compartment syndrome and other pressure-related complications. Neurovascular exams of the extremity are required before and after immobilization to assess for such complications. Supportive care consists of analgesia and thromboprophylaxis. Most affected individuals can receive outpatient care with short-term follow-up (e.g., 3–7 days); those with uncontrolled pain and/or the inability to perform activities of daily living may need to be admitted. Compartment syndrome, the most significant complication of fracture management, is threatening to life and limb; patients should be educated on compartment syndrome symptoms and return precautions.

Overviewtoggle arrow icon

General principles [1][2][3]

  • Conservative fracture treatment primarily consists of immobilization with or without closed reduction.
  • It can be started as initial management or continued as definitive management depending on fracture and patient characteristics.
  • Reduction and immobilization techniques vary depending on multiple factors
  • Orthopedics consultation during the index visit or in follow-up is recommended for most patients.

All suspected acute extremity fractures should be immobilized early to control pain and prevent complications.

Treatment options [1][2][3]

Indicationstoggle arrow icon

Contraindicationstoggle arrow icon

We list the most important contraindications. The selection is not exhaustive.

Technical backgroundtoggle arrow icon

Casts and splints are made of a rigid material (plaster or fiberglass) underlaid by stockinette and soft padding to protect the skin and held in place by an elastic bandage overwrap.

Splinting and casting material [1][4][5]

  • Plaster
    • Types
      • Rolls , strips , prefabricated rolls
      • “Fast drying” or “extra-fast drying”
    • Advantages: more time to fashion and mold
    • Disadvantages: longer application time, heavier, more easily damaged by water, higher risk of skin burns
  • Fiberglass
    • Options: rolls, prefabricated strips
    • Advantages: fast application time and lightweight [6]
    • Disadvantages: limited time to fashion and mold
  • SAM splint: a moldable splint made of soft aluminum with a foam coating that is mainly used in emergency settings to quickly and temporarily immobilize broken extremities.
  • Prefabricated splints
    • Options: large variety (e.g., finger, wrist, ankle, knee)
    • Advantages: no preparation required, easy and quick application
    • Disadvantages: limited customization options, less effective immobilization

Heat released during the plaster or fiberglass setting process may lead to thermal injuries, especially with fast-drying plaster. [2][7]

Adjunct splinting and casting materials [1][4][5]

  • Stockinette
    • Applied directly to the skin
    • Protects the skin and wicks away sweat
  • Cast padding
    • Wrapped circumferentially in 2–3 layers around the extremity
    • Prevents soft-tissue pressure injury
  • Elastic compression bandage
    • Wrapped loosely around the entire splint or cast and secured with metal clips
    • Holds the splint in position
  • Others (e.g., stretch-conforming gauze): can be added in different stages depending on local practice

Width and thickness selection [1][4][5]


Splinting material, stockinette, and padding width are chosen based on the extremity to be treated.

  • Hands and digits: 1–3 inches
  • Upper extremity: 3–4 inches
  • Lower extremity: 4–6 inches


Layers of splinting materials
Material Upper extremity Lower extremity
  • ∼ 8–10 layers
  • ∼ 10–15 layers
  • ∼ 5–6 layers
  • ∼ 8–10 layers

Procedure/applicationtoggle arrow icon

Injuries without fracture characteristics requiring urgent orthopedic consultation can be initially managed conservatively with closed reduction and immobilization. Definitive management varies depending on fracture characteristics; orthopedic casting or operative management may be required.

Closed reduction [3]

  • Definition: nonsurgical manipulation of a fractured bone (and/or dislocated joint) to restore its normal position and anatomic alignment
  • Techniques
    • Vary depending on the type and location of fracture
    • Typically performed by recreating and reversing the mechanism of injury
    • Often involves skeletal traction

Immobilization [2]

  • Goals: prevent fracture displacement, reduce pain, and protect the damaged area from injury
  • Duration: varies depending on patient and fracture characteristics but generally lasts 4–8 weeks.
  • Techniques: vary based on patient and fracture characteristics


  • Orthopedic splint: a rigid noncircumferential appliance used to immobilize a bone and/or joint
  • Orthopedic cast: a rigid circumferential appliance used to immobilize a bone and/or joint
  • Others
    • Soft removable appliances: e.g., slings, bandages, braces
    • Hard removable appliances: e.g., walking boot
    • Skeletal traction devices: e.g., halo device

Splinting is preferred over casting for immobilization in acute care settings. [2]

Perform a neurovascular exam before and after splint or cast application.

Skeletal traction [8]

  • Definition: the application of a pulling force on an injured body part to help realign shortened, angulated, and/or displaced fractures, and/or reduce joint dislocations
  • Goal: to overcome overlying muscle spasm and maintain anatomic alignment of the bones and joints
  • Clinical applications
    • Short-term traction (manual or device-based) is a component of many closed reduction techniques.
    • Long-term traction devices (e.g., using braces, pulleys, and/or weights) can be used for immobilization in both conservative and postsurgical fracture management.

Upper extremitiestoggle arrow icon

Orthopedic splints

The choice of splint is determined by fracture location and characteristics.

Common upper extremity splints [1][4][9]
Clinical applications Description Special considerations
Finger splint
  • Foam-padded metal or plastic splint
  • Placed on dorsal and/or volar side of finger
  • Interphalangeal (IP) joints immobilized
Radial gutter
  • Pad between the 4th and 5th fingers
Ulnar gutter
  • Pad between 2nd and 3rd fingers
Thumb spica
Sugar tong forearm splint
Volar splint
Dorsal splint (“Clamdigger”)
Long-arm posterior splint
  • Splinting material
  • Applied to the posterior arm and ulnar aspect of the forearm
  • Extends from below the axillary crease to midpalm
  • Elbow typically flexed to 90°
  • Forearm and wrist typically neutral
Long-arm anterior-posterior splint
  • The anterior and posterior slabs should not meet to become completely circumferential
Coaptation splint

Other immobilization devices

E.g., slings, bandages, braces, and orthotic devices made of flexible and/or elastic materials that are easily removable.

Clinical applications

Can be used in both initial and definitive management.

Shoulder immobilizers

  • Affected arm position
  • Arm sling
    • Bandage wraps the affected extremity's wrist, forearm, and elbow joint around the unaffected shoulder
    • Supports the weight of the arm and limits movement of the affected shoulder
  • Sling and swathe
    • Sling supports the weight of the arm
    • Swathe: an additional bandage that wraps the arm against thorax to prevent external rotation at the shoulder
  • Desault bandage: Bandages wrap the affected shoulder joint, upper arm, and elbow joint around the thorax.
  • Gilchrist bandage
    • One bandage wraps around both shoulders and affected wrist to support the weight of the arm and prevent external rotation at the affected shoulder
    • Another bandage wraps the distal upper arm against the thorax


Lower extremitiestoggle arrow icon

Orthopedic splints

The choice of splint is determined by fracture location and characteristics.

Common lower extremity splints [4][5][12]
Splint Clinical applications Description Special considerations

Posterior ankle splint

(Short-leg posterior splint; Lower leg backslab splint)

  • Use 15–20 layers of plaster/fiberglass if weight-bearing is planned.

Posterior long-leg splint

(Posterior knee splint)

Anterior-posterior ankle splint

Stirrup splint

(U-splint; Ankle sugar tong splint)

Combined posterior ankle splint and stirrup splint

(Lower leg three-sided slab splint)

  • Unstable ankle and foot fractures (e.g., postreduction)

Other immobilization devices

Walking boot

Hard shoe

  • Clinical applications
  • Description
    • Applied like a sandal, secured with velcro or ties
    • Often combined with buddy taping
    • Primarily used for pain reduction

Buddy taping

  • Clinical applications: uncomplicated phalangeal fractures of the lesser toes [13]
  • Description
    • The affected toe is bandaged to an unaffected toe with gauze applied in the interdigital space to prevent skin irritation and maceration.
    • Often combined with a hard shoe

Supportive caretoggle arrow icon

Supportive treatment

Cast care instructions [1][2]

Dispositiontoggle arrow icon

Disposition [3]

  • For inpatients who sustain fractures while admitted, consult orthopedics, assess patient safety, and determine if the local incident reporting system should be activated.
  • Most emergency department patients treated conservatively can be discharged after appropriate workup, immobilization, supportive care, and discharge planning is complete.
  • Outpatient follow-up (e.g., orthopedics, family medicine, return visit to emergency department) is typically required within 3–7 days.
  • Indications for admission for conservatively treated fractures include:
    • Inability to ambulate safely
    • Inability to perform ADLs
    • Risk of developing permanent disability
    • Inadequate pain management

Discharge planning [3]

Complicationstoggle arrow icon

Compartment syndrome is a life- and limb-threatening emergency. Promptly remove the constricting cast or splint and assess the limb of any patient with clinical features of compartment syndrome.

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. Purcell D, Chinai SA, Allen BR, Davenport M. Emergency Orthopedics Handbook. Springer ; 2019
  2. Reichman EF. Emergency Medicine Procedures, Second Edition. McGraw-Hill Education / Medical ; 2013
  3. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  4. Kowalski KL, Pitcher JD Jr, Bickley B. Evaluation of fiberglass versus plaster of Paris for immobilization of fractures of the arm and leg.. Mil Med. 2002; 167 (8): p.657-61.
  5. Hutchinson MJ, Hutchinson MR. Factors contributing to the temperature beneath plaster or fiberglass cast material. J Orthop Surg. 2008; 3 (1).doi: 10.1186/1749-799x-3-10 . | Open in Read by QxMD
  6. Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting.. Am Fam Physician. 2009; 79 (1): p.16-22.
  7. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  8. Testroote M, Stigter W, Janzing H, de Visser D. Low molecular weight heparin for prevention of venous thromboembolism in patients with lower leg immobilization. Cochrane Database Syst Rev. 2007.doi: 10.1002/14651858.cd006681 . | Open in Read by QxMD
  9. Boyd AS, Benjamin HJ, Asplund C. Splints and casts: indications and methods. Am Fam Physician. 2009; 80 (5): p.491-9.
  10. Gupta U, Verma M. Placebo in clinical trials. Perspectives in Clinical Research. 2013; 4 (1): p.49.doi: 10.4103/2229-3485.106383 . | Open in Read by QxMD
  11. Sherman SC. Simon's Emergency Orthopedics, 8th edition. McGraw Hill Professional ; 2018
  12. Won SH, Lee S, Chung CY, et al. Buddy Taping: Is It a Safe Method for Treatment of Finger and Toe Injuries?. Clinics in Orthopedic Surgery. 2014; 6 (1): p.26.doi: 10.4055/cios.2014.6.1.26 . | Open in Read by QxMD
  13. Weber DM, Seiler M, Subotic U, Kalisch M, Weil R. Buddy taping versus splint immobilization for paediatric finger fractures: a randomized controlled trial. J Hand Surg Eur Vol. 2019; 44 (6): p.640-647.doi: 10.1177/1753193418822692 . | Open in Read by QxMD
  14. Choudhry B, Leung B, Filips E, Dhaliwal K. Keeping the Traction on in Orthopaedics. Cureus. 2020.doi: 10.7759/cureus.10034 . | Open in Read by QxMD

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