Presentation on theme: "Closed Reduction, Traction, and Casting Techniques"— Presentation transcript:
1Closed Reduction, Traction, and Casting Techniques David Hak, MDOriginal Author: Dan Horwitz, MD; March 2004New Author: David Hak, MD; Revised January 2006, October 2008
2Closed Reduction Principles All displaced fractures should be reduced to minimize soft tissue complications, including those that require ORIFUse splints initiallyAllow for swellingAdequately pad all bony prominences
3Closed Reduction Principles Adequate analgesia and muscle relaxation are critical for successReduction maneuver may be specific for fracture location and patternCorrect/restore length, rotation, and angulationImmobilize joint above and below
4Closed Reduction Principles Reduction may require reversal of mechanism of injury, especially in children with intact periosteumWhen the bone breaks because of bending, the soft tissues disrupt on the convex side and remain intact on the concave sideFigure from Chapman’s Orthopaedic Surgery 3rd Ed. (Redrawn from Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963.)
5Closed Reduction Principles Longitudinal traction may not allow the fragments to be disimpacted and brought out to length if there is an intact soft-tissue hinge (typically seen in children who have strong perisoteum that is intact on one side)Figure from Chapman’s Orthopaedic Surgery 3rd Ed. (Redrawn from Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963.)
6Closed Reduction Principles Reproduction of the mechanism of fracture to hook on the ends of the fractureAngulation beyond 90° is usually requiredFigure from Chapman’s Orthopaedic Surgery 3rd Ed. (Redrawn from Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963.)
7Closed Reduction Principles Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.Three point contact (mold) is necessary to maintain closed reductionFigure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.Removal of any of the threeforces results in loss of reduction
8Closed Reduction Principles Cast must be molded to resist deforming forces“Straight casts lead to crooked bones”“Crooked casts lead to straight bones”
9Anesthesia for Closed Reduction Hematoma Block - aspirate hematoma and place 10cc of Lidocaine at fracture siteLess reliable than other methodsFast and easyTheoretically converts closed fracture to open fracture but no documented increase in infection
10Anesthesia for Closed Reduction IV SedationVersed – 1 mg q 3 minutes up to 5mgMorphine mg/kgDemerol mg/kg up to 150 mgBeware of pulmonary complications with deep conscious sedation - consider anesthesia service assistance if there is concernPulse oximeter and careful monitoring are recommended
11Anesthesia for Closed Reductions Bier Block - superior pain relief, greater relaxation, less premedication neededDouble tourniquet is inflated on proximal arm and venous system is filled with localLidocaine preferred for fast onsetVolume = 40ccAdults 2-3 mg/kg Children 1.5 mg/kgIf tourniquet is deflated after < 40 minutes then deflate for 3 seconds and re-inflate for 3 minutes - repeat twiceWatch closely for cardiac and CNS side effects, especially in the elderly
12Common Closed Reductions Distal RadiusLongitudinal tractionLocal or regional blockExaggerate deformityPush for length and reversal of deformityApply splint or cast with point moldFigure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.
13Common Joint Reductions Elbow Dislocation - traction, flexion, and direct manual pushFigures from Rockwood and Green, 5th edFigures from Rockwood and Green, 5th ed.
14Common Joint Reductions Shoulder Dislocation - relaxation, traction, gentle rotation if necessaryFigures from Rockwood and Green, 5th ed..Figures from Rockwood and Green, 5th ed.
15Common Joint Reductions Hip DislocationRelaxation, flexion, traction, adduction and internal rotationGentle and atraumaticFigures from Rockwood and Green, 5th ed.Relocation should be palpable and permit significantlyimproved ROM. This often requires very deep sedation.Figures from Rockwood and Green, 5th ed.
16Splinting Non-cicumferential – allows for further swelling May use plaster or prefab fiberglass splints(plaster molds better)
18Sugar Tong SplintSplint extends around the distal humerus to provide rotational controlPadding should be at least layers thick with several extra layers at the elbow
19Figure from Rockwood and Green, 4th ed. Humeral Shaft Fracture Coaptation SplintMedially splint ends in the axilla and must be well padded to avoid skin breakdownLateral aspect of splint extends over the deltoidFigure from Rockwood and Green, 4th ed.Figure from Rockwood and Green, 4th ed.
20Fracture Bracing Allows for early functional ROM and weight bearing Relies on intact soft tissues and muscle envelope to maintain alignment and lengthMost commonly used for humeral shaft and tibial shaft fractures
21Figure from Rockwood and Green, 4th ed. Convert to humeral fracture brace 7-10 days after fracture(i.e. when fracture site is not tender to compression).Allows early active elbow ROMFracture reduction maintained by hydrostatic column principleCo-contraction of muscles- Snug brace during the day- Do not rest elbow on tableFigure from Rockwood and Green, 4th ed.Patient must tolerate a snug fit for brace to be functionalFigure from Rockwood and Green, 4th ed.
22CastingGoal of semi-rigid immobilization while avoiding pressure / skin complicationsOften a poor choice in the treatment of acute fractures due to swelling and soft tissue complicationsGood cast technique necessary to achieve predictable results
23Casting TechniquesStockinette - may require two different diameters to avoid overtight or loose materialCaution not to lift leg by stockinette – stretching the stockinette too tight around the heel may case high skin pressure
24Figure from Chapman’s Orthopaedic Surgery 3rd Ed. Casting TechniquesTo avoid wrinkles in the stockineete, cut along the concave surface and overlap to produce a smooth contourFigure from Chapman’s Orthopaedic Surgery 3rd Ed.
25Figure from Chapman’s Orthopaedic Surgery 3rd Ed. Casting TechniquesCast paddingRoll distal to proximal50 % overlap2 layers minimumExtra padding at fibular head, malleoli, patella, and olecranonFigure from Chapman’s Orthopaedic Surgery 3rd Ed.
26Plaster vs. Fiberglass Plaster Fiberglass Use cold water to maximize molding timeFiberglassMore difficult to mold but more durable and resistant to breakdownGenerally times stronger for any given thickness
27Width Casting materials are available in various widths 6 inch for thigh3 - 4 inch for lower leg3 - 4 inch for upper arm2 - 4 inch for forearm
28Figure from Chapman’s Orthopaedic Surgery 3rd Ed. Cast MoldingAvoid molding with anything but the heels of the palm in order to avoid pressure pointsMold applied to produce three point fixationFigure from Chapman’s Orthopaedic Surgery 3rd Ed.
29Below Knee Cast Support metatarsal heads Ankle in neutral – flex knee to relax gastrocEnsure freedom of toesBuild up heel for walking casts - fiberglass much preferred for durability
30Padding for fibular head and plantar aspect of foot
31Assistant or foot stand required to maintain ankle position Flexed kneePadded fibularheadFigure from:Figure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders, pNeutral anklepositionToes freeAssistant or foot stand required to maintain ankle positionFigure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders,
32Figure from Chapman’s Orthopaedic Surgery 3rd Ed. Short Leg CastWhen working alone, the patient can help maintain proper ankle position by holding onto a muslin bandage placed beneath the toesFigure from Chapman’s Orthopaedic Surgery 3rd Ed.
33Above Knee Cast Apply below knee first (thin layer proximally) Flex knee degreesMold supracondylar femur for improved rotational stabilityApply extra padding anterior to patella
34Anterior padding Support lower leg / cast Extend to gluteal crease Figure from:Figure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders, p 2221,Figure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders,
35Forearm Casts & Splints MCP joints should be freeDo not go past proximal palmar creaseThumb should be free to base of MCOpposition of thumb to little finger should be unobstructed
37Examples - Position of Function Ankle - Neutral dorsiflexion – No EquinusHand - MCPs flexed 70 – 90º, IPs in extensionFigure from Rockwood and Green, 5th ed.70-90 degreesFigure from Rockwood and Green, 5th ed.
38Cast WedgingEarly follow-up x-rays are required to ensure reduction is not lostCast may be “wedged” to correct reductionDeformity is drawn out on castCast is cut circumferentiallyCast is wedged to correct deformity and the over-wrappedExample of cast wedging to correct loss of reduction of a pediatric distal both bone forearm fracture. From Halanski M, Noonan KJ. J Am Acad Orthop Surg
39Complications of Casts & Splints Loss of reductionPressure necrosis – may occur as early as 2 hoursTight cast compartment syndrome Univalving = 30% pressure drop Bivalving = 60% pressure dropAlso need to cut cast paddingLoss of reduction is the most common complication of cast treatment as the swelling decreases and the padding compresses while the patient regains mobility. Careful casting technique can avoid this (careful molding, attention to detail—deforming forces:gravity and muscle). Appropriately time radiographic reevaluation and correction of problems will lead to a satisfactory outcome.
40Complications of Casts & Splints Thermal Injury - avoid plaster > 10 ply, water >24°C, unusual with fiberglassCuts and burns during removalKeloid formation as a result of an injury during cast removal. From Halanski M, Noonan KJ. J Am Acad Orthop Surg
41Complications of Casts & Splints DVT/PE - increased in lower extremity fractureAsk about prior history and family historyBirth Control Pills are a risk factorIndications for prophylaxis controversial in patients without risk factorsJoint stiffnessLeave joints free when possible (ie. thumb MCP for below elbow cast)Place joint in position of function
42TractionAllows constant controlled force for initial stabilization of long bone fractures and aids in reduction during operative procedureOption for skeletal vs. skin traction is case dependent
43Skin TractionLimited force can be applied - generally not to exceed 5 lbsMore commonly used in pediatric patientsCan cause soft tissue problems especially in elderly or rheumatoid patientsNot as powerful when used during operative procedure for both length or rotational control
44Skin Traction - “Bucks” An option to provide temporary comfort in hip fracturesMaximal weight poundsWatch closely for skin problems, especially in elderly or rheumatoid patients
45Skeletal Traction More powerful than skin traction May pull up to 20% of body weight for the lower extremityRequires local anesthesia for pin insertion if patient is awakePreferred method of temporizing long bone, pelvic, and acetabular fractures until operative treatment can be performed
46Traction Pin Types Choice of thin wire vs. Steinman pin Thin wire is more difficult to insert with hand drill and requires a tension traction bowStandard BowTension Bow
47Traction Pin Types Steinmann pin may be either smooth or threaded Smooth is stronger but can slide if angledThreaded pin is weaker, bends easier with higher weight, but will not slide and will advance easily during insertionIn general a 5 or 6 mm diameter pin is chosen for adults
48Traction Pin Placement Sterile field with limb exposedLocal anesthesia + sedationInsert pin from known area of neurovascular structureDistal femur: Medial LateralProximal Tibial: Lateral MedialCalcaneus: Medial LateralPlace sterile dressing around pin sitePlace protective caps over sharp pin ends
49Distal Femoral Traction Method of choice for acetabular and proximal femur fracturesIf there is a knee ligament injury usually use distal femur instead of proximal tibial traction
50Distal Femoral Traction Place pin from medial to lateral at the adductor tubercle - slightly proximal to epicondyleFigures from Althausen PL, Hak DJ. Am J Orthop
51Balanced Skeletal Traction Allows for suspension of leg with longitudinal tractionRequires trapeze bar, traction cord, and pulleysProvides greater comfort and ease of movementAllows multiple adjustments for optimal fracture alignment
52One of many options for setting up balanced suspension Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.One of many options for setting up balanced suspensionIn general the thigh support only requires 5-10 lbs of weightNote the use of double pulleys at the foot to decrease the total weight suspended off the bottom of the bedFigure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.
53Proximal Tibial Traction Place pin 2 cm posterior and 1 cm distal to tuberclePlace pin from lateral to medialCut skin and try to stay out of anterior compartment - push muscle posteriorly with pin or hemostatFigures from Althausen PL, Hak DJ. Am J Orthop
54Figures from Althausen PL, Hak DJ. Am J Orthop. 2002. Calcaneal TractionMost commonly used with a spanning ex fix for “travelling traction” or may be used with a Bohler-Braun framePlace pin medial to lateral cm posterior and inferior to medial malleolusMedial StructuresLateral StructuresFigures from Althausen PL, Hak DJ. Am J Orthop
55Figure from Chapman’s Orthopaedic Surgery 3rd Ed. Olecranon TractionRarely used todaySmall to medium sized pin placed from medial to lateral in proximal olecranon - enter bone 1.5 cm from tip of olecranon and walk pin up and down to confirm midsubstance location.Support forearm and wrist with skin traction - elbow at 90 degreesFigure from Chapman’s Orthopaedic Surgery 3rd Ed.
56Gardner Wells Tongs Used for C-spine reduction / traction Pins are placed one finger breadth above pinna, slightly posterior to external auditory meatusApply traction beginning at 5 lbs. and increasing in 5 lb. increments with serial radiographs and clinical exam
57HaloIndicated for certain cervical fractures as definitive treatment or supplementary protection to internal fixationDisadvantagesPin problemsRespiratory compromise
58Left: “Safe zone” for halo pins Left: “Safe zone” for halo pins. Place anterior pins about 1 cm above orbital rim, over lateral two thirds of the orbit, and below skull equator (widest circumference).Right: “Safe zone” avoids temporalis muscle and fossa laterally, and supraorbital and supatrochlear nerves and frontal sinus medially.Posterior pin placement is much less critical because the lack of neuromuscular structures and uniform thickness of the posterior skull.Figure from: Botte MJ, et al. J Amer Acad Orthop Surg. 4(1): 44 – 53, 1996.
59Halo Application Position patient maintaining spine precautions Fit Halo ringPrep pin sitesAnterior - outer half above eyebrow avoiding supraorbital artery, nerve, and sinusPosterior - superior and posterior to earTighten pins to 6 - 8ft-lbs.Retighten if loosePins only once at 24 hoursFrame prnFigure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.
60ReferencesFreeland AE. Closed reduction of hand fractures. Clin Plast Surg Oct;32(4):Fernandez DL. Closed manipulation and casting of distal radius fractures. Hand Clin Aug;21(3):Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg Jan;16(1):30-40.Bebbington A, Lewis P, Savage R. Cast wedging for orthopaedic surgeons. Injury. 2005;36:71-72.
61ReferencesHalanski MA, Halanski AD, Oza A, et al. Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. J Bone Joint Surg Am Nov;89(11):Althausen PL, Hak DJ. Lower extremity traction pins: indications, technique, and complications. Am J Orthop Jan;31(1):43-7.Alemdaroglu KB, Iltar S, Çimen O, et al.Risk Factors in Redisplacement of Distal Radial Fractures in Children. J Bone Joint Surg Am. 2008; 90:Sarmiento A, Latta LL. Functional fracture bracing. J Am Acad Orthop Surg Jan;7(1):66-75.
62Classical ReferencesSarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am Jul;59(5):Sarmiento A, Sobol PA, Sew Hoy AL, et al. Prefabricated Functional Braces for the Treatment of Fractures of the Tibial Diaphysis. JBone and Joint Surg A:Sarmiento A, Latta LL. 450 closed fractures of the distal third of the tibia treated with a functional brace. Clin Orthop Relat Res Nov;(428):Sarmiento A. Fracture bracing. Clin Orthop Relat Res Jul-Aug;(102):152-8.
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