Closed Reduction, Traction, and Casting TechniquesDavid Hak, MD

Original Author: Dan Horwitz, MD; March 2004New Author: David Hak, MD; Revised January 2006, October 2008

Closed Reduction PrinciplesAll 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

Closed Reduction PrinciplesAdequate analgesia and muscle relaxation are critical for successReduction maneuver may be specific for fracture location and pattern Correct/restore length, rotation, and angulationImmobilize joint above and below

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

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

Closed Reduction PrinciplesReproduction of the mechanism of fracture to hook on the ends of the fractureAngulation beyond 90 is usually requiredFigure from Chapmans Orthopaedic Surgery 3rd Ed. (Redrawn from Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963.)

Closed Reduction PrinciplesThree point contact (mold) is necessary to maintain closed reductionRemoval of any of the threeforces results in loss of reduction

Closed Reduction PrinciplesCast must be molded to resist deforming forcesStraight casts lead to crooked bonesCrooked casts lead to straight bones

Anesthesia for Closed ReductionHematoma 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

Anesthesia for Closed ReductionIV SedationVersed - 0.5 1 mg q 3 minutes up to 5mgMorphine - 0.1 mg/kgDemerol - 1- 2 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

Anesthesia for Closed ReductionsBier 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 onset Volume = 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

Common Closed ReductionsDistal Radius Longitudinal tractionLocal or regional blockExaggerate deformityPush for length and reversal of deformityApply splint or cast with 3-point moldFigure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.

Common Joint ReductionsElbow Dislocation - traction, flexion, and direct manual pushFigures from Rockwood and Green, 5th ed.

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

Common Joint ReductionsHip DislocationRelaxation, flexion, traction, adduction and internal rotationGentle and atraumaticRelocation should be palpable and permit significantly improved ROM. This often requires very deep sedation.Figures from Rockwood and Green, 5th ed.

SplintingNon-cicumferential allows for further swellingMay use plaster or prefab fiberglass splints(plaster molds better)

Common Splinting TechniquesBulky JonesSugar-tongCoaptationUlnar gutterVolar / Dorsal handThumb spicaPosterior slab (ankle) +/- U splintPosterior slab (thigh)

Sugar Tong SplintSplint extends around the distal humerus to provide rotational controlPadding should be at least 3 - 4 layers thick with several extra layers at the elbow

Medially splint ends in the axilla and must be well padded to avoid skin breakdown

Lateral aspect of splint extends over the deltoidFigure from Rockwood and Green, 4th ed.Humeral Shaft Fracture Coaptation Splint

Fracture BracingAllows for early functional ROM and weight bearingRelies on intact soft tissues and muscle envelope to maintain alignment and lengthMost commonly used for humeral shaft and tibial shaft fractures

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 principleCo-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.

CastingGoal 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

Casting 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

Casting TechniquesTo avoid wrinkles in the stockineete, cut along the concave surface and overlap to produce a smooth contourFigure from Chapmans Orthopaedic Surgery 3rd Ed.

Casting TechniquesCast paddingRoll distal to proximal 50 % overlap2 layers minimumExtra padding at fibular head, malleoli, patella, and olecranonFigure from Chapmans Orthopaedic Surgery 3rd Ed.

Plaster vs. FiberglassPlasterUse cold water to maximize molding timeFiberglass More difficult to mold but more durable and resistant to breakdown Generally 2 - 3 times stronger for any given thickness

WidthCasting materials are available in various widths6 inch for thigh 3 - 4 inch for lower leg 3 - 4 inch for upper arm 2 - 4 inch for forearm

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

Below Knee CastSupport metatarsal headsAnkle in neutral flex knee to relax gastroc Ensure freedom of toesBuild up heel for walking casts - fiberglass much preferred for durability

Padding for fibular head and plantar aspect of foot

Padded fibular headFlexed kneeNeutral anklepositionToes freeAssistant or foot stand required to maintain ankle positionFigure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders, 1998.

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

Above Knee CastApply below knee first (thin layer proximally)Flex knee 5 - 20 degreesMold supracondylar femur for improved rotational stabilityApply extra padding anterior to patella

Anterior paddingSupport lowerleg / castExtend to gluteal creaseFigure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders, 1998.

Forearm Casts & SplintsMCP joints should be free Do not go past proximal palmar creaseThumb should be free to base of MC Opposition of thumb to little finger should be unobstructed

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Examples - Position of FunctionAnkle - Neutral dorsiflexion No EquinusHand - MCPs flexed 70 90, IPs in extension70-90 degreesFigure from Rockwood and Green, 5th ed.

Cast 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. 2008.

Complications of Casts & SplintsLoss of reductionPressure necrosis may occur as early as 2 hoursTight cast compartment syndrome Univalving = 30% pressure drop Bivalving = 60% pressure drop Also need to cut cast padding

Complications of Casts & SplintsThermal Injury - avoid plaster > 10 ply, water >24C, 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. 2008.

Complications of Casts & SplintsDVT/PE - increased in lower extremity fracture Ask about prior history and family historyBirth Control Pills are a risk factorIndications for prophylaxis controversial in patients without risk factorsJoint stiffness Leave joints free when possible (ie. thumb MCP for below elbow cast)Place joint in position of function

TractionAllows 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

Skin 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

Skin Traction - BucksAn option to provide temporary comfort in hip fracturesMaximal weight - 10 pounds Watch closely for skin problems, especially in elderly or rheumatoid patients

Skeletal TractionMore powerful than skin tractionMay 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

Traction Pin TypesChoice of thin wire vs. Steinman pinThin wire is more difficult to insert with hand drill and requires a tension traction bowTension BowStandard Bow

Traction Pin TypesSteinmann 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

Traction Pin PlacementSterile 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

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

Distal Femoral TractionPlace pin from medial to lateral at the adductor tubercle - slightly proximal to epicondyle

Figures from Althausen PL, Hak DJ. Am J Orthop. 2002.

Balanced Skeletal TractionAllows 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

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

Proximal Tibial TractionPlace 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. 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 2 - 2.5 cm posterior and inferior to medial malleolusMedial StructuresLateral StructuresFigures from Althausen PL, Hak DJ. Am J Orthop. 2002.

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 Chapmans Orthopaedic Surgery 3rd Ed.

Gardner Wells TongsUsed for C-spine reduction / tractionPins 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

HaloIndicated for certain cervical fractures as definitive treatment or supplementary protection to internal fixationDisadvantagesPin problemsRespiratory compromise

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.

Halo ApplicationPosition patient maintaining spine precautionsFit 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.

ReferencesFreeland 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.

ReferencesHalanski 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, imen 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.

Classical 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. 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.

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

*Figures from Rockwood and Green, 5th ed*Figures from Rockwood and Green, 5th ed..*Figures from Rockwood and Green, 5th ed.*Figure from Rockwood and Green, 4th ed.*Figure from Rockwood and Green, 4th ed.*Figure from:Figure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders, p 2221 1998.

*Figure from:Figure from: Browner and Jupiter: Skeletal Trauma, 2nd ed, Saunders, p 2221, 1998.

*Figure from Rockwood and Green, 5th ed.*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 detaildeforming forces:gravity and muscle). Appropriately time radiographic reevaluation and correction of problems will lead to a satisfactory outcome.*Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.

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