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Closed Reduction, Traction, and Casting Techniques David Hak, MD Original Author: Dan Horwitz, MD; March 2004 New Author: David Hak, MD; Revised January.

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Presentation on theme: "Closed Reduction, Traction, and Casting Techniques David Hak, MD Original Author: Dan Horwitz, MD; March 2004 New Author: David Hak, MD; Revised January."— Presentation transcript:

1 Closed Reduction, Traction, and Casting Techniques David Hak, MD Original Author: Dan Horwitz, MD; March 2004 New Author: David Hak, MD; Revised January 2006, October 2008

2 Closed Reduction Principles All displaced fractures should be reduced to minimize soft tissue complications, including those that require ORIF Use splints initially –Allow for swelling –Adequately pad all bony prominences

3 Closed Reduction Principles Adequate analgesia and muscle relaxation are critical for success Reduction maneuver may be specific for fracture location and pattern Correct/restore length, rotation, and angulation Immobilize joint above and below

4 Closed Reduction Principles Reduction may require reversal of mechanism of injury, especially in children with intact periosteum When the bone breaks because of bending, the soft tissues disrupt on the convex side and remain intact on the concave side Figure from Chapmans Orthopaedic Surgery 3 rd Ed. (Redrawn from Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963.)

5 Closed 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 Chapmans Orthopaedic Surgery 3 rd Ed. (Redrawn from Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963.)

6 Closed Reduction Principles Reproduction of the mechanism of fracture to hook on the ends of the fracture Angulation beyond 90° is usually required Figure from Chapmans Orthopaedic Surgery 3 rd Ed. (Redrawn from Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963.)

7 Closed Reduction Principles Three point contact (mold) is necessary to maintain closed reduction Removal of any of the three forces results in loss of reduction Figure from: Rockwood and Green: Fractures in Adults, 4 th ed, Lippincott, 1996.

8 Closed Reduction Principles Cast must be molded to resist deforming forces Straight casts lead to crooked bones Crooked casts lead to straight bones

9 Anesthesia for Closed Reduction Hematoma Block - aspirate hematoma and place 10cc of Lidocaine at fracture site –Less reliable than other methods –Fast and easy –Theoretically converts closed fracture to open fracture but no documented increase in infection

10 Anesthesia for Closed Reduction IV Sedation Versed - 0.5 – 1 mg q 3 minutes up to 5mg Morphine - 0.1 mg/kg Demerol - 1- 2 mg/kg up to 150 mg –Beware of pulmonary complications with deep conscious sedation - consider anesthesia service assistance if there is concern –Pulse oximeter and careful monitoring are recommended

11 Anesthesia for Closed Reductions Bier Block - superior pain relief, greater relaxation, less premedication needed Double tourniquet is inflated on proximal arm and venous system is filled with local –Lidocaine preferred for fast onset –Volume = 40cc –Adults 2-3 mg/kg Children 1.5 mg/kg –If tourniquet is deflated after < 40 minutes then deflate for 3 seconds and re-inflate for 3 minutes - repeat twice –Watch closely for cardiac and CNS side effects, especially in the elderly

12 Common Closed Reductions Distal Radius Longitudinal traction Local or regional block Exaggerate deformity Push for length and reversal of deformity Apply splint or cast with 3-point mold Figure from: Rockwood and Green: Fractures in Adults, 4 th ed, Lippincott, 1996.

13 Common Joint Reductions Elbow Dislocation - traction, flexion, and direct manual push Figures from Rockwood and Green, 5 th ed.

14 Common Joint Reductions Shoulder Dislocation - relaxation, traction, gentle rotation if necessary Figures from Rockwood and Green, 5 th ed.

15 Common Joint Reductions Hip Dislocation Relaxation, flexion, traction, adduction and internal rotation Gentle and atraumatic Relocation should be palpable and permit significantly improved ROM. This often requires very deep sedation. Figures from Rockwood and Green, 5th ed.

16 Splinting Non-cicumferential – allows for further swelling May use plaster or prefab fiberglass splints (plaster molds better)

17 Common Splinting Techniques Bulky Jones Sugar-tong Coaptation Ulnar gutter Volar / Dorsal hand Thumb spica Posterior slab (ankle) +/- U splint Posterior slab (thigh)

18 Sugar Tong Splint Splint extends around the distal humerus to provide rotational control Padding should be at least 3 - 4 layers thick with several extra layers at the elbow

19 Medially splint ends in the axilla and must be well padded to avoid skin breakdown Lateral aspect of splint extends over the deltoid Figure from Rockwood and Green, 4 th ed. Humeral Shaft Fracture Coaptation Splint

20 Fracture Bracing Allows for early functional ROM and weight bearing Relies on intact soft tissues and muscle envelope to maintain alignment and length Most commonly used for humeral shaft and tibial shaft fractures

21 Convert to humeral fracture brace 7-10 days after fracture (i.e. when fracture site is not tender to compression). Allows early active elbow ROM Fracture reduction maintained by hydrostatic column principle Co-contraction of muscles - Snug brace during the day - Do not rest elbow on table Patient must tolerate a snug fit for brace to be functional Figure from Rockwood and Green, 4th ed.

22 Casting Goal of semi-rigid immobilization while avoiding pressure / skin complications Often a poor choice in the treatment of acute fractures due to swelling and soft tissue complications Good cast technique necessary to achieve predictable results

23 Casting Techniques Stockinette - may require two different diameters to avoid overtight or loose material Caution not to lift leg by stockinette – stretching the stockinette too tight around the heel may case high skin pressure

24 Casting Techniques To avoid wrinkles in the stockineete, cut along the concave surface and overlap to produce a smooth contour Figure from Chapmans Orthopaedic Surgery 3 rd Ed.

25 Casting Techniques Cast padding –Roll distal to proximal –50 % overlap –2 layers minimum –Extra padding at fibular head, malleoli, patella, and olecranon Figure from Chapmans Orthopaedic Surgery 3 rd Ed.

26 Plaster vs. Fiberglass Plaster –Use cold water to maximize molding time Fiberglass – More difficult to mold but more durable and resistant to breakdown – Generally 2 - 3 times stronger for any given thickness

27 Width Casting materials are available in various widths –6 inch for thigh – 3 - 4 inch for lower leg – 3 - 4 inch for upper arm – 2 - 4 inch for forearm

28 Figure from Chapmans Orthopaedic Surgery 3 rd Ed. Avoid molding with anything but the heels of the palm in order to avoid pressure points Mold applied to produce three point fixation Cast Molding

29 Below Knee Cast Support metatarsal heads Ankle in neutral – flex knee to relax gastroc Ensure freedom of toes Build up heel for walking casts - fiberglass much preferred for durability

30 Padding for fibular head and plantar aspect of foot

31 Padded fibular head Flexed knee Neutral ankle position Toes free Assistant or foot stand required to maintain ankle position Figure from: Browner and Jupiter: Skeletal Trauma, 2 nd ed, Saunders, 1998.

32 Short Leg Cast When working alone, the patient can help maintain proper ankle position by holding onto a muslin bandage placed beneath the toes Figure from Chapmans Orthopaedic Surgery 3 rd Ed.

33 Above Knee Cast Apply below knee first (thin layer proximally) Flex knee 5 - 20 degrees Mold supracondylar femur for improved rotational stability Apply extra padding anterior to patella

34 Anterior padding Support lower leg / cast Extend to gluteal crease Figure from: Browner and Jupiter: Skeletal Trauma, 2 nd ed, Saunders, 1998.

35 Forearm Casts & Splints MCP joints should be free –Do not go past proximal palmar crease Thumb should be free to base of MC –Opposition of thumb to little finger should be unobstructed

36 x x

37 Examples - Position of Function Ankle - Neutral dorsiflexion – No Equinus Hand - MCPs flexed 70 – 90º, IPs in extension 70-90 degrees Figure from Rockwood and Green, 5 th ed.

38 Cast Wedging Early follow-up x-rays are required to ensure reduction is not lost Cast may be wedged to correct reduction Deformity is drawn out on cast Cast is cut circumferentially Cast is wedged to correct deformity and the over-wrapped Example 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. 2008.

39 Complications of Casts & Splints Loss of reduction Pressure necrosis – may occur as early as 2 hours Tight cast compartment syndrome Univalving = 30% pressure drop Bivalving = 60% pressure drop Also need to cut cast padding

40 Complications of Casts & Splints Thermal Injury - avoid plaster > 10 ply, water >24°C, unusual with fiberglass Cuts and burns during removal Keloid formation as a result of an injury during cast removal. From Halanski M, Noonan KJ. J Am Acad Orthop Surg. 2008.

41 Complications of Casts & Splints DVT/PE - increased in lower extremity fracture –Ask about prior history and family history –Birth Control Pills are a risk factor –Indications for prophylaxis controversial in patients without risk factors Joint stiffness –Leave joints free when possible (ie. thumb MCP for below elbow cast) –Place joint in position of function

42 Traction Allows constant controlled force for initial stabilization of long bone fractures and aids in reduction during operative procedure Option for skeletal vs. skin traction is case dependent

43 Skin Traction Limited force can be applied - generally not to exceed 5 lbs More commonly used in pediatric patients Can cause soft tissue problems especially in elderly or rheumatoid patients Not as powerful when used during operative procedure for both length or rotational control

44 Skin Traction - Bucks An option to provide temporary comfort in hip fractures Maximal weight - 10 pounds Watch closely for skin problems, especially in elderly or rheumatoid patients

45 Skeletal Traction More powerful than skin traction May pull up to 20% of body weight for the lower extremity Requires local anesthesia for pin insertion if patient is awake Preferred method of temporizing long bone, pelvic, and acetabular fractures until operative treatment can be performed

46 Traction Pin Types Choice of thin wire vs. Steinman pin Thin wire is more difficult to insert with hand drill and requires a tension traction bow Tension Bow Standard Bow

47 Traction Pin Types Steinmann pin may be either smooth or threaded –Smooth is stronger but can slide if angled –Threaded pin is weaker, bends easier with higher weight, but will not slide and will advance easily during insertion In general a 5 or 6 mm diameter pin is chosen for adults

48 Traction Pin Placement Sterile field with limb exposed Local anesthesia + sedation Insert pin from known area of neurovascular structure –Distal femur: Medial Lateral –Proximal Tibial: Lateral Medial –Calcaneus: Medial Lateral Place sterile dressing around pin site Place protective caps over sharp pin ends

49 Distal Femoral Traction Method of choice for acetabular and proximal femur fractures If there is a knee ligament injury usually use distal femur instead of proximal tibial traction

50 Distal Femoral Traction Place pin from medial to lateral at the adductor tubercle - slightly proximal to epicondyle Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.

51 Balanced Skeletal Traction Allows for suspension of leg with longitudinal traction Requires trapeze bar, traction cord, and pulleys Provides greater comfort and ease of movement Allows multiple adjustments for optimal fracture alignment

52 One of many options for setting up balanced suspension In general the thigh support only requires 5-10 lbs of weight Note the use of double pulleys at the foot to decrease the total weight suspended off the bottom of the bed Figure from: Rockwood and Green: Fractures in Adults, 4 th ed, Lippincott, 1996.

53 Proximal Tibial Traction Place pin 2 cm posterior and 1 cm distal to tubercle Place pin from lateral to medial Cut skin and try to stay out of anterior compartment - push muscle posteriorly with pin or hemostat Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.

54 Calcaneal Traction Most commonly used with a spanning ex fix for travelling traction or may be used with a Bohler-Braun frame Place pin medial to lateral 2 - 2.5 cm posterior and inferior to medial malleolus Medial Structures Lateral Structures Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.

55 Olecranon Traction Rarely used today Small 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 degrees Figure from Chapmans Orthopaedic Surgery 3 rd Ed.

56 Gardner Wells Tongs Used for C-spine reduction / traction Pins are placed one finger breadth above pinna, slightly posterior to external auditory meatus Apply traction beginning at 5 lbs. and increasing in 5 lb. increments with serial radiographs and clinical exam

57 Halo Indicated for certain cervical fractures as definitive treatment or supplementary protection to internal fixation Disadvantages –Pin problems –Respiratory compromise

58 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.

59 Halo Application Position patient maintaining spine precautions Fit Halo ring Prep pin sites –Anterior - outer half above eyebrow avoiding supraorbital artery, nerve, and sinus –Posterior - superior and posterior to ear Tighten pins to 6 - 8ft-lbs. Retighten if loose –Pins only once at 24 hours –Frame prn Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.

60 References Freeland AE. Closed reduction of hand fractures. Clin Plast Surg. 2005 Oct;32(4):549-61. Fernandez DL. Closed manipulation and casting of distal radius fractures. Hand Clin. 2005 Aug;21(3):307-16. Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg. 2008 Jan;16(1):30-40. Bebbington A, Lewis P, Savage R. Cast wedging for orthopaedic surgeons. Injury. 2005;36:71-72.

61 References Halanski MA, Halanski AD, Oza A, et al. Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. J Bone Joint Surg Am. 2007 Nov;89(11):2369-77. Althausen PL, Hak DJ. Lower extremity traction pins: indications, technique, and complications. Am J Orthop. 2002 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: 1224 - 1230. Sarmiento A, Latta LL. Functional fracture bracing. J Am Acad Orthop Surg. 1999 Jan;7(1):66-75.

62 Classical References Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am. 1977 Jul;59(5):596- 601. 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. 1984. 66-A: 1328- 1339. Sarmiento A, Latta LL. 450 closed fractures of the distal third of the tibia treated with a functional brace. Clin Orthop Relat Res. 2004 Nov;(428):261-71. Sarmiento A. Fracture bracing. Clin Orthop Relat Res. 1974 Jul-Aug;(102):152-8.

63 Questions Return to General/Principles Index E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.orgota@aaos.org


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