What is the treatment for a unicortical fracture?

Treatment of Unicortical Fracture

Unicortical fractures generally require conservative management with immobilization and monitoring, though surgical fixation may be indicated for displaced fractures or those at high risk of progression to complete fracture.

Initial Assessment and Risk Stratification

The clinical presentation of unicortical fractures can be deceptively mild, with minimal palpable abnormality despite significant underlying pathology 1. This creates a critical diagnostic challenge—failure to detect and appropriately treat these injuries can lead to catastrophic complete fracture 1.

Key diagnostic considerations:

• Standard radiographs may miss unicortical fractures; specialized views (such as flexed projections) or advanced imaging like MRI may be necessary for diagnosis 1
• The location and extent of cortical involvement determines prognosis and treatment approach 2
• High-energy mechanisms increase risk of complications and may warrant more aggressive management 3

Treatment Algorithm

Non-Operative Management (First-Line for Stable Fractures)

Most unicortical fractures respond well to conservative treatment 1. The approach includes:

• Rigid immobilization with splinting is preferred over removable splints, particularly for any degree of displacement 4
• Duration of immobilization should be individualized based on fracture healing, typically several weeks 4
• Serial radiographic monitoring is essential to detect progression to complete fracture 1

Important caveat: Conservative management carries a reinjury risk of approximately 16.7% at a median of 305 days, which must be weighed against surgical risks 1.

Surgical Management (For Displaced or High-Risk Fractures)

Surgery is indicated when 4, 1:

• Multiple fractures are present
• There is significant displacement
• Conservative management has failed
• High risk of progression to catastrophic fracture exists

Surgical technique considerations:

• Unicortical fixation is sufficient for most applications and avoids unnecessary soft tissue trauma 5
• Lag screw technique provides adequate stability for articular fractures 6
• "Reduction plating" using unicortical plates can maintain provisional reduction in complex cases 7
• Bicortical fixation offers no outcome advantage over unicortical fixation and may increase morbidity 5

Rehabilitation Protocol

Early mobilization is critical to optimize functional outcomes 4, 6. The rehabilitation program should include:

• Immediate or early mobilization following surgical fixation to prevent stiffness 6
• Muscle strengthening exercises throughout recovery 4
• Long-term continuation of exercises (minimum 6 months) 4, 6
• Patient education regarding pain management strategies and warning signs of complications 4

Expected outcomes with proper treatment:

• Return to activity rates exceed 90% with appropriate management 1, 5
• Average time to activity clearance is approximately 18-20 weeks for surgical cases 5
• Final range of motion can approach 90% of normal with optimal surgical technique and therapy 6

Critical Pitfalls to Avoid

• Misdiagnosis or delayed diagnosis is the most serious error, potentially leading to catastrophic complete fracture 1
• Inadequate immobilization increases risk of displacement and nonunion 4
• Failure to monitor for progression—serial imaging is mandatory 1
• Premature return to activity before adequate healing increases reinjury risk 1

Special Considerations

For fractures in weight-bearing bones or high-stress locations, maintain heightened vigilance for progression 1. The overall nonunion rate for lower extremity fractures is approximately 9%, but can reach 75% in high-energy injuries 3. Early surgical intervention should be strongly considered in these high-risk scenarios to prevent progression to nonunion or complete fracture 1, 3.