Basic Principles of Reduction Maneuvers

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Chapter 8 Basic Principles of Reduction Maneuvers

The three-point principle

1. Diaphyseal fractures (Figure 8-1, A):

a. The primary reductive force should be applied against the apex of the fracture.
b. Counterforce applied in the opposite direction both proximal and distal to the apex stabilizes the limb.
2. Metaphyseal/epiphyseal fractures (Figure 8-1, B):

a. The primary reductive force should be applied just distal to the fracture.
b. Counterforce should be applied in the opposite direction just proximal to the fracture and in the same direction as the primary force at the proximal end of the bone.
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Figure 8-1

Exaggerating the deformity

1. Indications for reduction by exaggerating the deformity:

a. Fully displaced fractures with an intact periosteal hinge (typically in children) and bayonet apposition (Figure 8-2)
b. Fracture fragments that will not disengage with traction and/or direct reduction maneuvers (Figure 8-3)
c. Rarely indicated for diaphyseal fractures

2. The principle of this reduction method is to:

a. Disengage the fracture fragments (Figure 8-4)
b. Allow direct reduction methods to succeed (Figure 8-5)

3. Technique:

a. Begin with manually applied traction and countertraction.
b. Place a thumb or two just proximal to the fracture on the side opposite the apex as a fulcrum.
c. Apply a point of counterforce proximal to the fracture on the side of the apex.
d. Exaggerate the deformity by accentuating the apex so that the angulation of the fracture exceeds 90 degrees.
e. Using the thumb(s), push distalward, moving the fulcrum more distal.
f. Correct the deformity and reduce the fracture.

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Figure 8-2

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Figure 8-3

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Figure 8-4

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Figure 8-5

The value of traction

1. Overcoming muscle force:

a. The skeleton counteracts the contractile forces of the muscles.
b. Muscles pulling against a broken bone will shorten it.
c. Fractures and muscle injury result in involuntary muscle spasm.
d. Traction allows the bone to be restored to its proper length by overcoming muscle contraction and spasm.
e. The amount of traction applied should exceed the amount of muscle spasm.

2. Disimpacting fractures:

a. Fracture fragments can become locked by interdigitating.
b. Distraction allows for reduction by translation.

3. Taking advantage of the soft tissue envelope:

a. Comminuted fractures can be reduced by hydrostatic pressure.
b. Intact tendons, muscles, and periosteum can directly reduce areas of comminution.

4. Applying traction:

a. Double digit construct:

(1) Make a loop of gauze with your left hand.
(2) Place your right thumb and index finger inside the loop in supination (Figure 8-6).
(3) While holding one side of the gauze taut with the left hand, spread your right index finger and thumb apart, then pronate your right forearm (Figure 8-7).
(4) Your index finger and thumb should now be outside the loop.
(5) Bring the tips of your index finger and thumb together and pull the loops out with your index finger (Figure 8-8).
(6) Place each of the newly formed traction loops around each of the fingers or toes to which traction will be applied (Figure 8-9).
(7) Make sure the transverse limb connecting both traction loops is behind the free end of the gauze (Figure 8-10).
(8) Attach the free end of the gauze to an intravenous line pole or another well-anchored elevation device.

b. Single digit construct (Figure 8-11):

(1) Follow the outlined steps for the double digit construct, but place both traction loops around same digit (Figure 8-12).
c. Alternatively, commercially available Chinese finger traps may be used (Figure 8-13).

(1) We have found that Chinese finger traps are liable to come loose during the application of traction.
(2) Mastisol or benzoin may be applied to the skin to prevent finger trap migration.
d. Use commercially available weight trees to attach the weights and provide traction (Figure 8-14).

(1) If a weight tree is not available:

(a) Take a 4-foot length of stockinette and securely tie one end.
(b) Place two 5-lb weights inside the stockinette.
(c) Securely tie the other end.
(d) Separate the two weights and place the stockinette over the arm (Figure 8-15).

(2) If weights are not available, use large intravenous bags (Figure 8-16) in place of the weights and follow the aforementioned procedure.

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Figure 8-6

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Figure 8-7

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Figure 8-8

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Figure 8-9

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Figure 8-10

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Figure 8-11

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Figure 8-12

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Figure 8-13

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Figure 8-14

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Figure 8-15

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Figure 8-16

Physeal injuries

1. Reduction of a Salter-Harris fracture (Figure 8-17) should be attempted only after one is skilled with adult fractures and extraphyseal pediatric fractures in that region.
2. A level of anesthesia that will limit muscle spasm and involuntary or voluntary muscle contraction should be attained and may be achieved through one of the following methods:

a. General anesthesia
b. Conscious sedation
c. Dissociative anesthesia (ketamine)

3. The number of reduction attempts should be limited to one or two.
4. Use of excessive force should be avoided.
5. More traction than is typical should be used to fully disengage the fracture before attempting a reduction.
6. Traction should be maintained throughout reduction maneuvers.
7. Repeated and/or forceful reduction attempts may further damage the physis and result in physeal arrest or bar formation.

a. A consequence may be limited growth or angulation of the limb.
b. This complication is very difficult to treat.

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Figure 8-17

Joint reductions

1. Principles similar to those of fracture reduction apply to joint reduction.
2. A satisfying “clunk” is usually heard upon successful joint reduction.
3. Soft tissue interposition and buttonholing may preclude joint reduction.

Precautions

1. Avoid placing either primary force or counterforce directly over the following potential sites of nerve compression when molding a splint or cast or when obtaining a reduction in plaster:

a. Axilla
b. Cubital tunnel
c. Carpal tunnel
d. Femoral triangle
e. Popliteal fossa
f. Fibular head
g. Tarsal tunnel

2. Use broad surfaces such as the palm of the hand for the reduction whenever possible to distribute force over a larger area.
3. The exaggeration of deformity technique should be used with caution and only when direct reduction techniques fail. An intact periosteal hinge prevents reduction by direct means but prevents over-reduction and complete destabilization of the fracture.
4. When a fracture fragment or joint is buttonholed through fascia or between two tendons/ligaments, traction will complicate the reduction.

a. If reduction becomes more difficult with traction, try the reduction without traction.
b. If all reduction attempts fail, consider soft tissue interposition as a cause, obtain the best reduction possible, and make arrangements for an open reduction in the operating room.

Pearls

1. If the periosteal hinge is intact, it is nearly impossible to over-reduce the fracture.
2. To correct angulation only, a three-point bend is sufficient.
3. To correct translation only, use traction to disengage the fragments, then apply a correcting force just distal to the fracture as well as a counterforce just proximal to the fracture.
4. To correct rotation, flex the next most distal joint and use the direction of flexion as a guide and a handle to dial in rotation.
5. Use a leg, a knee, or the stretcher to provide counterforce if necessary.

Improvisation

1. When all else fails, develop a clear picture of the fracture in your head and then imagine how you would intuitively reduce it.
2. Each fracture is different, and improvisation is encouraged after standard techniques have failed.

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