Reduction techniques
1 Introduction 91
2 Goals of reduction 91
2.1 Articular fractures 91
2.2 Diaphyseal fractures 91
3 Reduction principles 91
3.1 Direct reduction techniques 92
3.2 Indirect reduction techniques 95
4 Summary 100
5 References 100
6 Further reading 100
Introduction
Fracture reduction using minimally invasive techniques can be a challenging but rewarding experience for both patient and surgeon. The goal of creating the smallest surgical disturbance while gaining optimal reduction can be achieved in most cases. Maintenance of the blood supply is more important than the length of the incision. Reduction techniques require a clear understanding of the goals of reduction and knowledge of the deforming forces, the limits and capabilities of the reduction tools and implants, the preoperative x-ray anatomy, and the intraoperative local anatomy. Lastly, experience in open surgery and its attendant principles is key to successful minimally invasive surgery.
Goals of reduction
An understanding of the goals of fracture reduction is fundamental in formulating an appropriate treatment plan. It will affect the approach and the degree of reduction necessary to optimize the result for the patient.
Articular fractures
Restoration of extremity function after trauma is dependent on free and painless function of the associated joints. Multiple studies [ 1– 4] have recognized the importance of anatomical restoration of the articular surface but even the clearest studies supporting the use of anatomical reduction show that other processes affect chondrocyte survival [ 5, 6]. Until we are able to define and control these other processes, anatomical reduction of the cartilage surface is the most important goal in the treatment of articular fractures because this is the only way that surgeons can influence the end functional result. Also important is the restoration of the anatomical axis of the limb, particularly in the lower extremity. Long-term studies have shown that a malaligned limb following treatment can lead to higher rates of arthritis [6, 7].
Diaphyseal fractures
With the exception of the forearm, the goal of treating diaphyseal fractures is to achieve length, alignment, and rotation identical to the contralateral limb. For multifragmentary fractures of the diaphysis, the fracture is spanned to achieve these goals. In simple fractures, however, absolute stability by fixation with compression across the fracture site protects the implant, decreases pain that may occur with functional aftercare, and promotes union. This is consistent with the basic principles of fracture treatment and both goals can be achieved with minimally invasive techniques using either direct or indirect reduction.
Reduction principles
Fracture reduction, both direct and indirect, can be made easier in several ways before the actual incision is made.
Preoperative planning is key to the execution of minimally invasive osteosynthesis. Understanding the fracture x-rays, possible approaches, intended implant, and potential dangers are critical to safe and successful surgery.
Timing is important. Early reduction and fixation will facilitate reduction in minimally invasive surgery but should be done only in cases with good soft-tissue condition. The reason for this caution is that a fracture, which cannot be reduced by minimally invasive techniques, will need to be opened. In case of a patient presenting late with a fracture or a patient with severe swelling, indirect reduction will be more difficult because the fracture ends have begun to heal. The fracture may then need to be opened and directly reduced to achieve the stated goals.
Muscle relaxation is strongly recommended. Anesthetic relaxation via chemical paralysis of the patient or regional anesthesia will facilitate reduction by minimizing the resistance of the deforming muscular forces.
The setup of the patient on the operating table is critical and several important points need to be considered. There should be no obstruction to x-ray evaluation. Use of a radiolucent table as well as a trial with the image intensifier before preparing the skin and draping the patient ensures that optimal imaging can be obtained. The ideal situation is when orthogonal x-ray views can be obtained without moving the extremity being reduced.
Setup can include the use of bumps ( Fig 6-1 ), radiolucent triangles (see Fig 6-7 ), or packaged linen and all these must be available. These pieces of equipment are used to stabilize the operative field, aid in the reduction, and maintain the fracture when it has been reduced.
Use of a fracture table, external fixator, or the large distractor (see Fig 6-3c ) should also be considered as part of the setup. All three instruments serve to stabilize the operative field by maintaining length. If an external fixator or large distractor is used, this should be inserted before attempting the reduction.
Direct reduction techniques
Displaced intraarticular and simple fractures require anatomical reduction to achieve excellent functional results and to minimize complications. Anatomical reduction typically requires exposure of the fracture and direct reduction.
Incisions should allow visualization of both articular and simple fractures. For example, in the distal femur a parapatellar incision or a transarticular approach and retrograde plate osteosynthesis (TARPO) [ 8] allow for excellent access to nearly the entire articular surface ( Fig 6-2 ). This allows for direct reduction, clamp application, and fixation. Small accessory incisions can be used to facilitate reduction as in employing a stab incision on the medial aspect of the distal femur for insertion of a Schanz screw to be used as a joystick for the distal medial femoral condyle.
Handling the soft tissues at the fracture should be done sparingly. To see the fracture reduction one should peel back only 1–2 mm of soft tissue at the fracture ends so that after reduction the exact reduction can be appreciated ( Fig 6-3 ).
Pointed reduction forceps ( Fig 6-5c ), larger clamps, and joysticks can then be used to manipulate the fragments to obtain reduction. Use of the 8 mm sharp Hohmann retractor is an elegant way to reduce a fracture ( Fig 6-4 ). The goal is minimal disturbance of the soft tissues as well as avoidance of crushing metaphyseal bone.
Reduction of metaphyseal fragments is key to establishing the proper joint orientation and support. Ligamentotaxis can aid in reduction of the metaphysis and more rarely the epiphysis. The use of broad instruments, such as osteotomes and elevators, facilitates mobilization of crushed metaphyseal fragments.
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