Closed Fracture Treatment: Reduction, Holding Reduction and Exercise

Closed fracture treatment include following the pattern of reduce, hold and exercise; in this article you will learn about all of these…

Principles of closed fracture treatment include:

Reduction: manipulation of the fragments to reach the normal anatomical position
Holding the reduction (retaining reduction): holding the fragments together until they unite
Exercise the joints proximal and distal and get the patient back to normal function

1. Reduction is the first step in closed fracture treatment

this is the first step in closed fracture treatment
Reduction = returning the fracture fragments to their normal anatomical positions
This procedure comes after stabilizing the patient
Swelling of soft tissue in the first 12 hours after injury make reduction difficult
During reduction, you should aim for adequate apposition and normal alignment of bone fragments
The greater the contact surface area between fragments, the more likely healing is to occur
Some overlap at the fracture surfaces is okay as long as the fracture is in location other than the articular surface
Articular surface fractures should be reduced as near to perfection as possible because any irregularity might lead to abnormal load distribution and predispose to degenerative changes at the joint

Some situations in which reduction is unnecessary

When there is little or no displacement
When displacement doesn’t matter initially (in clavicle fractures)
When reduction is unlikely to succeed (e.g. in vertebral compression fractures)

Types of reduction

Closed reduction
Open reduction

Closed reduction

Analgesia, local anesthesia or general anesthesia might be used depending on the situation for pain and muscle relaxation
Then reduction is done either through manipulation or through traction
Manipulation done through these three steps:
1. The distal part of the limb is pulled in the line of the bone
2. As the fragments disengage, they are repositioned by applying force that is opposite to the force caused the fracture
3. Alignment is then adjusted in each plane
Or done through traction which reduces fracture fragments through ligamentotaxis (ligament pulling) which is applicable to specific fractures
Closed reduction is most effective when the periosteum and muscles on one side of the fracture remain intact (stable fracture), preventing over reduction and stabilize fracture after reduction
Some fractures are difficult to reduce due to powerful muscle pull, so prolonged traction is needed
Closed reduction is mostly adequate for all minimally displaced fractures
Closed reduction is used for unstable fractures in emergency settings to be fixated at later times in theatre
Closed reduction fails because either it is difficult to control fracture fragments or fracture fragments are stuck because soft tissue is interposed between them

Open reduction

Means operative opening of the fracture site and reduction under direct vision
Indications
1. When closed reduction fails
2. When it is an articular fracture that can’t be reduced accurately when closed
3. For avulsion fractures (because avulsed fragment is connected to a muscle that continuously pulls it away)

2. Retaining reduction (Holding reduction) is the second step in closed fracture treatment

The second step after reduction for the closed fracture treatment
Previously called immobilization but the term not scientifically right because it is rarely complete immobility, in most cases there is still little movements at fracture site and those are good for healing; but the term (immobilization) still used a lot
So it means that you hold fracture in place until healing occurs
You need a form of stabilization to the fracture site that hold it in place while the patient is able to exercise the joints proximal and distal to it
Holding reduction is achieved using various closed and open methods
Closed methods
- Continuous traction
- Cast splintage
- Functional bracing
Open methods
- Internal fixation
- External fixation
Closed Holding methods are more suitable for fractures with intact soft tissues and muscles because intact muscles and soft tissue act as support to the fracture with the holding method used
Open holding methods used in fractures with severe soft tissue damage, e.g. unstable fractures, multiple fractures, fractures in non cooperative patient
Next we will talk about the types of holding reduction methods

Types of Holding reduction

Those include:

Continuous traction
Cast splintage
Functional bracing
Internal fixation
external fixation

Continuous traction

Continuous traction is mostly used as a reduction method nowadays for closed fracture treatment, and it is used as a holding method only as a bridging procedure to relieve pain until patient reaches operating room for open holding method to be applied
Normally muscles attached proximal and distal to fracture site will pull the fragments towards each other and displace the fracture
The idea behind traction is you counter the muscle pulling by pulling the limb the opposite side
that is why traction is applied to the distal part of the limb to pull it away from the fracture site, thus countering the muscle pulling
Of course once you are pulling the distal part , you need some stabilization to the patient body so it doesn’t all get pulled
Traction is useful for shaft fractures (because they are highly affected by muscle pull), especially oblique and spiral fractures that are easily displaced by muscle contraction, it can also be used for acetabular fractures with femoral head subluxation or dislocation
Traction cannot hold a fracture still, it can pull a long bone and hold it out to length but to maintain accurate reduction is difficult; that is why nowadays traction is used as bridging procedure to reduce the fracture and relieve pain until the operation is done to the patient for internal or external fixation of the fracture
Traction includes three methods:
1. Traction by gravity: this applied to upper limb injuries only (mostly humeral shaft fractures)
  - wrist sling (U-slab) is applied and it provides a continuous traction using the weight of the arm to pull it downward
2. Skin traction: used for lower limbs mostly, allows a traction weight of no more than 4-5 kg
  - Holland strapping or one way stretch Elastoplast are applied to shaved skin and held on with bandage and connected to a weight
3. Skeletal traction: a pin is inserted usually behind the tibial tuberosity and connected to weight for hip, thigh and knee injuries or through calcaneum for tibial fractures

Complications of traction

Skin irritation
Pressure sores
Discomfort or pain
Circulation compromise: check pulses after applying
Nerve injury especially with skeletal traction (common perioneal nerve injury and foot drop)
Pin site infection with skeletal traction

Cast splintage

Closed holding method
The most common holding reduction method for closed fracture treatment
Plaster of Paris is mostly used for casting in emergency department because it is versatile, easy to handle and strong but the downside that it is heavy
Other materials like fiberglass or polypropylene are lighter and used for definitive casting but they are harder to handle
Casting is used either to create a split cast (backslab) or full cast

Backslabs

Is a Split cast applied to one side of the injured limb to act as a splint
Casting material used in slabs is several layers thick
Doesn’t allow three point fixation thus provides less fracture support in comparison to full cast
Used in emergency settings only
It allows swelling of the limb in comparison with full cast
Easily applied and easily removed with a scissor only

Backslabs types

U-slab: provide continuous traction in humeral shaft fractures
Above elbow slab: used for distal humerus fracture, elbow dislocations and forearm fracture
Wrist slab: for distal radius and scaphoid fractures
Volar hand slab: for metacarpal and phalangeal fractures
Thumb spica: for base of thumb fracture and first metacarpophalangeal joint injury
Above knee slab for tibial plateau fracture, tibial shaft fracture and knee dislocation
Below knee slab for ankle fracture and foot injury

Full casts

Casting material in a full circle around the limb to provide support
layers built up, one on the other, until the cast get the desired strength
Full cast can be molded to shape allowing three point fixation and provide better fracture support than a backslab
Full cast require more experience
Harder to remove in the event of swelling and circulatory compromise, so if you expect the limb to swell then don’t apply it until swelling subside or apply with thick padding

Casting technique

After reduction of the fracture, preparation of the materials and equipment
Then padding with cotton or synthetic materials applied to skin and bony prominences
Application of plaster of Paris or any other casting material
Wait for it to dry and harden usually about 15- 30 minutes
Follow up: watch for swelling if casting is done as emergency

Disadvantages of casting

Joints included in the cast can’t move and liable to stiffness
Articular fractures need movement for the articular cartilage to heal but with casting articular fractures can’t move
Tight cast: cast maybe put tightly or become tight after swelling, patient complains of pain, check for vascular compromise => split the cast and ease it open through its length and through padding; if swelling is anticipated thick padding is used and plaster splitted before it sets
Loose cast: after swelling subsided, cast become loose => should be replaced
Pressure sores: esp. bony prominences , patient complains of localized pain on the pressure spot => make a window through the cast and inspect the pain site
Skin abrasions and laceration: it is a complication of removing the cast, esp. if electric saw is used

Functional bracing

Closed holding method
Device used to stabilize the fracture, same as a cast but it is already made and has many variations depending on the bone that is broken
More convenient than a cast
Functional means patient can resume normal movements, there is also other types of braces like rehabilitative and prophylactic but functional is what we used in fractures
Bracing is also referred to as orthosis
Allow patient to adjust tightness of the device, remove it and wash it, and if used in lower limbs then allows walking better than a cast
Used for stable injuries and after surgical stabilization of fractures
Examples: moon boots, hinged braces, wrist splints and mallet splints

Internal fixation

Open holding method (surgical method)
Internal meaning all the devices used to fixate and stabilize the fracture are inside, nothing is popping out of the skin
In internal fixation, implants of various types used depending on the situation, they include: screws, plates, tension band wire, intramedullary nails

Indications of internal fixation

Fractures that can’t be reduced by closed reduction, because once you use open reduction, it is obligatory to use open holding method which is either internal or external fixation
Unstable fractures that are prone to displace after reduction
Avulsion fractures
Pathological fractures because bone healing is impaired
Multiple fractures where early fixation reduce risk of general complications
fractures in patient who present nursing difficulties (paraplegic, very elderly)

Screws

Device that convert rotational force into compressive one (to hold bone fragments together)
Contain head and shaft, the head has a socket which can accommodate a screw driver; the shaft has a core and thread
Separation distance between threads is called pitch which equals the distance the screw travels when turned 360 degrees
Screw types according to shape:
cortical screw has small diameter and pitch suitable for stabilizing dense cortical bone
cancellous screw has a larger diameter and pitch which provide better grip in more porous cancellous bone
Locking screws are used with locking plates and have threads in their heads
Lag screws used to compress fracture fragments together

Plates

Device applied to the exterior of a bone to maintain alignment and reduction during bone healing, this device is held by screws
Plates functions includes
- neutralization (protection) plate is used with a lag screw to control torsional forces between bone fragments
- Compression plate used to compress two bone fragments together and used for diaphyseal fractures
- Buttress plate is used to resist shear forces, especially in metaphyseal fractures
- Bridging plate bridges simple or multi fragmentary fractures to restore correct length, axis and rotation

Tension band wire

Metallic wire used in case the fracture fragments are too fragile to be fixed with plating
Examples in olecranon fractures, medial malleolus, patella …

Intramedullary nails

Long rod inserted in medullary bony canal (intramedullary)
Standard of care for diaphyseal bone fractures of lower limb, mostly femoral shaft fractures
Rotational forces resisted by adding interlocking screws to the nail

Complications of internal fixation

Infection: iatrogenic because orthopedics implant increase the risk of infection, infection lead to chronic osteomyelitis
Non union: when there is a gap between the fixed bones, or there is damage to the blood supply during the fixation process
Implant failure: if the device not capable of supporting the full load transferred through the limb
Refracture: if the implants removed sooner than a year, safe removal should be after 18- 24 months

External fixation

Open holding method (surgical method)
external meaning parts of the devices used to fixate and stabilize the fracture are popping out of the skin, using external fixator devices
Types of external fixation include uniplanar, multiplanar, unilateral, bilateral and circular and this is achieved using the fixator device which held by pins and wires

Indications of external fixation

Temporary stabilization of fractures in cases of
- severe soft tissue damage including open fractures to allow for re debridment
- Extensive contamination where internal fixation is risky
- Patients with severe multiple injuries (chest, abdomen, head) or with multiple fractures
Fractures around joints where the soft tissue is swollen and internal fixation is risky
Bone lengthening
Infected fractures

Complications of external fixation

Damage to soft tissue structures: nerves, vessels, ligaments
Non union: if there is gaps between fragments
Pin track infection

3. Exercise is the third step in closed fracture treatment

Exercise = restoring function of the injured limb and the patient as a whole
this is the third step in closed fracture treatment
Exercising lead to reduction of the edema, preserve joint movement, restore muscle power and guide patient back to normal activity
The holding reduction method should allow patient to fully use of the affected limb immediately after the procedure but in practice that is not always the case
Certain injuries require limiting function to avoid displacement during healing
Movement restriction prolong hospital stay and lead to joint stiffness
Patient encouraged to:
- Active exercise: helps pumping away edema fluid, stimulate circulation, prevents soft tissue adhesion and promotes fracture healing; if limb is encased in Plaster of Paris then static muscle contraction is taught to the patient, after removing the splint then joint mobilized; the unaffected joints should be exercised too
- Assisted movements: gentle assistance

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This article is apart from Orthopedic Trauma Basic Principles Course, This course covers these topics: