1. Fracture reduction AO Trauma Advanced Principles Course
Published: July 2013
Author: Rodrigo Pesantez
Reviewed: 2018
Reviewer: Rodrigo Pesantez
AO Trauma Advanced Principles Course

2. Learning objectives
Describe benefits and hazards of direct and indirect reduction
Describe principles of minimally invasive surgery
List indications for direct reduction
Summarize indications for indirect reduction
Relate the length of skin incision to the underlying soft-tissue dissection

3. Reduction
The action of remedying a dislocation or fracture by returning the affected part of the body to its normal position
A critical step in fracture care
Think about it during preoperative planning
Often the reduction is given less consideration than the method of stabilization. In reality, the reduction is generally the more important determinant of outcome.

4. Methods Direct reduction:
Fragment exposure and direct fragment manipulation to achieve reduction
Reduction visually assessed at the fracture line
Clamp placement
Direct reduction

5. Methods Indirect reduction: Blind reposition of fragments
Performed without direct fragment manipulation
Open, closed, or percutaneously
Reduction assessed by imaging or anatomical relationships
Distraction
Indirect reduction

6. Problem 1 ________________________ Quality of reduction α
Maintenance of blood supply
The more you try to get an anatomical reduction, the more you strip the soft tissues, however, the more you respect the soft tissues, the less perfect reductions you get.
Understanding this trade-off is essential. You need to know when the biologic “cost” of an anatomical reduction is warranted.
References:
Graves M, 2010

7. Solution: understand two things
Part of the bone broken
Epiphysis: anatomical reduction
Metaphysis and diaphysis: functional reduction
Strain theory
Simple fractures:
Absolute stability
Anatomical reduction
Complex fractures:
Relative stability
Functional reduction
You have to understand two things: the part of the bone that is broken and Perren’s strain theory.
First, if the bone is broken in the epiphysis (articular injury), then an anatomical reduction of the fracture fragments is required. On the other hand, if the bone is broken at the metaphysis or diaphysis only a functional reduction is needed (ie, restoration of length, alignment, rotation and spatial relationship of the joints [restore axis of the limb]).
According to the strain theory, in simple fracture patterns you provide absolute stability. In order to achieve it, you need an anatomical reduction of the fracture fragments. In complex fracture patterns (especially in metadiaphyseal bone) you need to provide relative stability, and in order to achieve that you need a functional reduction.

8. The goal is to achieve the quality of reduction required for each specific injury as atraumatically as possible. Matt Graves, 2010

9. Diminishing surgical footprints. Peter A Cole
Whether we use open approaches or minimally invasive surgery, we need to decrease the amount of damage we do to the soft tissues and to bone circulation. The size of the skin incision is not what matters. It is what we do to the underlying soft tissues, respecting anatomical planes during approaches, and sound knowledge of surgical anatomy that are of paramount importance.

10. Indications for direct reduction
Articular fractures
Simple configuration fractures
Minimize bone devitalization
Violation of the soft-tissue envelope and potential injury to osseous blood flow is offset by the benefits of anatomical fragment reduction and stability

11. Indications for indirect reduction
Extraarticular multifragmentary fractures
Metaphyseal or diaphyseal fractures with soft tissues compromised and concerns for the potential of skin healing:
Systemic disease
Soft-tissue injury

12. Direct reduction—incision and exposure
Long incisions to minimize tension on soft tissues
Full fasciocutaneous flaps—avoid skin flaps and retraction
Leave periosteum intact
Work inside and through fracture lines
Minimize soft-tissue stripping of fracture fragments

13. Indirect reduction—incision and exposure
First reduction:
Traction (manual, external fixation, distractor, fracture table)
Bumps, mallets, joysticks
Implant as reduction aid
Knowledge of surgical anatomy:
Work through soft-tissue windows

14. Minimally invasive surgery principles
Approaches: soft-tissue windows
Reduction: minimize additional soft-tissue and bone injury
Stable fixation according to fracture pattern
Diminishing surgical footprints

15. Direct reduction techniques

16. Direct reduction techniques
In this simple diaphyseal fracture we performed an anatomical reduction through a minimally invasive anterolateral approach to the fracture and then fixed it with two lag screws, and then through a minimally invasive anterior approach we slid a neutralization plate.

17. Direct reduction techniques
Note the small amount of stripping, and the careful placement of the retractors.

18. Direct reduction techniques
Direct, anatomical reduction of simple fracture pattern, absolute stability. Minimal surgical trauma.

19. Direct reduction techniques

20. Articular fractures require a good understanding of the fragments, and displacement.

21. Direct reduction techniques
The CT scan helps us see the displaced fragments. Articular fractures require anatomical reduction, which can generally be accomplished only with an open, direct reduction.

22. Direct reduction techniques
Open anterolateral approach, use of a femoral distractor to expose better the joint.
Submeniscal radial arthrotomy

23. Direct reduction techniques
Here you can see the distractor and the sutures for the meniscus retraction. The small rake retractor is opening the fracture side to expose the depression of the joint in order to elevate it.

24. Direct reduction techniques
Elevation of the joint is done with an impactor.

25. Direct reduction techniques
Use of pointed reduction forceps to close the fracture site once anatomical elevation and reduction of the joint have been achieved.
Preliminary fixation with K-wires.

26. Direct reduction techniques
Images from C-arm: Use of pointed reduction forceps to close the fracture site once anatomical elevation and reduction of the joint have been achieved.
Preliminary fixation with K-wires.

27. Correction of both the depression and the split components of the fracture.

28. Indirect reduction techniques

29. Many extraarticular fractures are reduced well enough with indirect means. The goal is to reduce this fracture well enough so that the bone apposition helps support the construct.

30. Traction on a fracture table in scissors position and C-arm images of fracture reduction.

31. Indirect reduction techniques
Final fixation.

32. Indirect reduction techniques
Complex floating knee, with a segmental femoral shaft and a simple tibial shaft.
Another example of extraarticular fractures.
The goal is restoration of axial limb alignment.

33. Indirect reduction techniques
Use of a femoral distractor to reduce the femur and 2 joysticks with Schanz pins to manipulate the fracture fragments.
This is a combination of indirect reduction with the distractor, and direct reduction with the percutaneously applied Schanz screws.

34. Indirect reduction techniques
Sequential reduction

35. Indirect reduction techniques
IM nail inside the femur and the femoral distractor in place.

36. Indirect reduction techniques
Restoration of alignment achieved with the methods shown.

37. Weber B ankle fracture with shortening of the fibula.

38. Indirect reduction techniques
Indirect reduction using a plate, push screw, and laminar spreader to regain length.

39. Indirect reduction techniques

40. Restoration of length of the fibula has also reduced the medial malleolus.

41. Indirect reduction techniques

42. Antiglide plating: interference reduction
An undercontoured antiglide plate applied at the apex of an axially unstable oblique fracture. The deformation of the plate with screw application will apply a reduction force to the bone.

44. Indirect reduction techniques

45. Fracture of the distal femur and proximal tibia.

46. CT scan shows that in addition to the fracture of the distal femoral metaphyseal-diaphyseal junction, there is a coronal (Hoffa) fracture of the medial femoral condyle. There is also a split fracture of the tibial plateau.

47. Indirect reduction of metadiaphyseal part
The articular fractures require an open, direct, anatomical reduction. In order to preserve blood supply and soft-tissue integrity, the extraarticular fracture is treated with an indirect reduction with use of the distractor.

48. Direct reduction of articular fractures
Anatomical articular reduction.

49. Absolute stability with lag screw fixation.

50. Bridge plate application at the extraarticular femoral fracture.

51. Expected healing.

53. Take-home messages—direct reduction
Fragment exposure and direct manipulation of fracture fragments:
Articular fractures
Simple configuration fractures
May use many of the techniques employed for indirect reduction

54. Take-home messages—indirect reduction
Use of tools or implants (distraction) without direct manipulation of fracture fragments
Indication for extraarticular multifragmentary fractures
Possibilities for technique are limitless
Key to successful management is the ability to select and perform appropriate fracture maneuvers for a particular fracture pattern