The Three-Point Principle
- 1.
Diaphyseal fractures ( Fig. 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.
Fig. 8.1
- a.
- 2.
Metaphyseal/epiphyseal fractures ( Fig. 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.
- a.
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 ( Fig. 8.2 )
Fig. 8.2
- b.
Fracture fragments that will not disengage with traction and/or direct reduction maneuvers ( Fig. 8.3 )
Fig. 8.3
- c.
Rarely indicated for diaphyseal fractures
- a.
- 2.
The principle of this reduction method is to:
- a.
Disengage the fracture fragments ( Fig. 8.4 ).
Fig. 8.4
- b.
Allow direct reduction methods to succeed ( Fig. 8.5 ).
Fig. 8.5
- a.
- 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 to 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.
- a.
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.
- a.
- 2.
Disimpacting fractures:
- a.
Fracture fragments can become locked by interdigitating.
- b.
Distraction allows for reduction by translation.
- a.
- 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.
- a.
- 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 ( Fig. 8.6 ).
- (1)
- a.
