2.10 Reduction techniques

10.1055/b-0034-85587

2.10 Reduction techniques

Definition of fracture reduction
Direct reduction
Indirect reduction
Conclusion
Further reading

Author Paul Szypryt

2.10 Reduction techniques

2.10.1 Definition of fracture reduction

Fracture reduction is the exact or near restoration of the correct position of fracture fragments, in other words restoring the anatomical shape of a broken bone. In shaft fractures that do not involve the joint surface reduction involves the restoration of the correct length, axis, and rotation of the fractured bone but does not necessarily involve putting all the bone framents back into their anatomical position (functional reduction). To do so might involve further damage to the blood supply of the bone fragments and their soft-tissue attachments leading to problems with fracture healing. In fractures involving a joint, perfect reduction of the joint surface and restoration of the mechanical axis of the limb is necessary for normal joint function (anatomical reduction). Because fractures of the shaft of the radius and ulna require perfect reduction of the fractures to achieve normal function, fractures of these bones are regarded as joint fractures when considering reduction requirements and technique.

Reduction usually involves reversal of the deforming forces that led to the displacement of the bony fragments. It is important to be highly vigilant at all times to avoid further damage to both the fracture fragments and the surrounding soft-tissue envelope.

There are two types of techniques that can be used to achieve fracture reduction.

2.10.2 Direct reduction

Direct reduction, as its name implies, involves the direct visualization and manipulation of the fracture fragments with hands or instruments through limited surgical exposure. This technique is particularly relevant in simple (two-part) diaphyseal fractures when closed reduction has failed, and in intraarticular fractures where perfect restoration of joint congruity is critical to restore function and limit disability.

Assessment of direct reduction

This is accomplished by direct observation of the fracture fragments in the surgical field, allowing assessment of the bone ends to determine if anatomical reconstruction has been achieved (like matching pieces of a puzzle).

The fracture ends are usually controlled by reduction forceps and/or bone clamps (Figs 2.10-1 and 2.10-2).

Fig 2.10-1a–b Direct manual reduction using two-pointed reduction forceps. a Each main fragment is held with a pointed reduction forceps. b Reduction is achieved by manual traction, while correct rotation and axial alignment can be controlled with the forceps.

Sometimes a plate precontoured to fit the anatomy of the bone can be used to aid the reduction. An example of this technique is the antiglide plate. Tightening a precontoured plate onto the bone reduces the fracture (Figs 2.10-3 and 2.10-4). Another example of the use of a plate to achieve reduction is the “push-pull” technique. The plate is precontoured to fit the bone. It is attached to one side of the fracture. A screw is inserted approximately 1–2 cm from the end of the plate. A bone spreader is then used to achieve distraction of the fracture. Once reduction has been obtained a Verbrugge clamp can be used to achieve compression at the fracture site (2.10-4).

Fig2.10-2a–c Direct reduction of an oblique fracture using one pointed reduction forceps. a Unreduced fracture. b Both fragments are held with a slightly tilted reduction forceps. c By gently rotating and tightening the forceps the fracture is reduced.

Fig 2.10-3a–c Indirect reduction with a plate functioning in antiglide mode. a Posteriorly displaced fracture (type B) of the lateral malleolus. b A 4-hole one-third tubular plate is fixed posterior to the proximal fragment. c Tightening of the proximal screw forces the distal fragment into a reduced position where it is firmly held by the plate. A second screw adds to the stability.

Fig 2.10-4a–b Push-pull technique. a A bone spreader placed between the end of a plate and an independent screw can be used to distract or push apart the fracture to facilitate reduction. b Using the same screw, interfragmentary compression can then be obtained by pulling the plate end toward the screw.

It is essential that intraoperative x-rays or image intensifier views in two planes, at 90° to each other, are obtained to assess not only the quality of reduction of the fracture but also to confirm reduction in that part of the bone not directly seen. Imaging is also important to ensure that the overall length and alignment has been restored.

Problems associated with this type of reduction are:

First, it involves direct exposure of the fracture via surgical incisions—often through a damaged soft-tissue envelope.
Second, in such circumstances overenthusiastic surgical expo sure can further damage the blood supply of the skin flaps and bone ends.
Third, direct reduction involves handling of the fracture frag ments using bone clamps, which can further damage the deli cate blood supply to the fracture fragments and periosteum.

Fig 2.10-5a–b a Galleazi fracture of the forearm. b Fracture anatomically reduced and fixed with a lag scew and a protection plate to provide absolute stability.

To avoid these problems if open reduction is deemed the best option to enable adequate treatment of a certain fracture type, the following are mandatory:

Delay surgery until soft tissues are healthy. This may take between 5 days for fracture with moderate soft-tissue swelling and 3 weeks for fractures with severe soft-tissue damage, especially pilon fractures.
Careful planning of surgical incisions to optimize exposure but minimize soft-tissue damage.
Careful handling of soft tissues and bone fragments throughout the operation.

This type of reduction is usually accompanied by fixation techniques producing absolute stability leading to direct bone healing. It is a technique most suited to simple diaphyseal/metaphyseal fractures and intraarticular fractures when accurate reduction and early movement are important to improve outcome (Figs 2.10-5 and 2.10-6).

Fig 2.10-6a–b a Fracture of the lateral tibial plateau. Note the depression of the articular surface of the joint. b Anatomical reduction and rigid fixation achieved with a buttress plate and lag screws.

Direct reduction is not an appropriate treatment for multifragmentary fractures of the diaphysis and metaphysis because of the damage it does of the blood supply to the bone fragments.

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