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

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

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 – 1 mg q 3 minutes up to 5mg
Morphine mg/kg
Demerol 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 point mold
Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.
Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.

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

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

15. Common Joint Reductions
Hip Dislocation
Relaxation, flexion, traction, adduction and internal rotation
Gentle and atraumatic
Figures from Rockwood and Green, 5th ed.
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 layers thick with several extra layers at the elbow

19. Figure from Rockwood and Green, 4th ed.
Humeral Shaft Fracture Coaptation Splint
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, 4th ed.
Figure from Rockwood and Green, 4th ed.

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. Figure 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 ROM
Fracture reduction maintained by hydrostatic column principle
Co-contraction of muscles
- Snug brace during the day
- Do not rest elbow on table
Figure from Rockwood and Green, 4th ed.
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. Figure from Chapman’s Orthopaedic Surgery 3rd Ed.
Casting Techniques
To avoid wrinkles in the stockineete, cut along the concave surface and overlap to produce a smooth contour
Figure from Chapman’s Orthopaedic Surgery 3rd Ed.

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

26. Plaster vs. Fiberglass Plaster Fiberglass
Use cold water to maximize molding time
Fiberglass
More difficult to mold but more durable and resistant to breakdown
Generally 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 Chapman’s Orthopaedic Surgery 3rd Ed.
Cast Molding
Avoid molding with anything but the heels of the palm in order to avoid pressure points
Mold applied to produce three point fixation
Figure from Chapman’s Orthopaedic Surgery 3rd Ed.

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

32. Figure from Chapman’s Orthopaedic Surgery 3rd Ed.
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 Chapman’s Orthopaedic Surgery 3rd Ed.

33. Above Knee Cast Apply below knee first (thin layer proximally)
Flex knee 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:Figure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders, p 2221,
Figure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders,

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
Figure from Rockwood and Green, 5th ed.
70-90 degrees
Figure from Rockwood and Green, 5th 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

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
Loss 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.

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

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 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
Standard Bow
Tension 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

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
Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.
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, 4th 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

54. Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.
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 cm posterior and inferior to medial malleolus
Medial Structures
Lateral Structures
Figures from Althausen PL, Hak DJ. Am J Orthop

55. Figure from Chapman’s Orthopaedic Surgery 3rd Ed.
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 Chapman’s Orthopaedic Surgery 3rd 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
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.
Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.

60. References
Freeland 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.

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 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.

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 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.

63. Questions
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