Hello Everyone,
Today I’ll be discussing the principles of closed fracture reduction in the emergency department. At MMC Main, we are lucky enough to have a responsive orthopedic surgery team available to us- however, this may not be the case out in the community. Knowing the basic principles of fracture reduction is crucial to restoring orthopedic function, particularly when neurovascular compromise is present.
General Indications for Fracture Reduction by the ED:
Closed fracture
- If open: consult orthopedics and administer TDAP and antibiotics
Displaced fracture
- If non-displaced or minimally displaced, then proceed with a splint- reduction is not needed
- If angulated, comminuted, intraarticular, delayed
presentation, or physeal in children: consult orthopedics for possible surgical
fixation
Location of fracture
-ED fracture reductions are only indicated for certain anatomical locations. Be sure to verify whether orthopedic management is mandatory for the injury at hand.
Quick plug for a mobile application called “Fractures.app” (EMRA-endorsed and a cousin of “sutures.app” and “nerveblock.app”) that provides indications and techniques for reduction, splinting, and follow up recommendations based on anatomical location of fracture.
Preparing for Fracture Reduction:
1. Establish mechanism and neurovascular status
2. Obtain X-rays to confirm fracture
3. Pain control: Consider IV pain medications, hematoma block, procedural sedation, nerve block, intraarticular block
Hematoma Blocks can be a low-risk and efficient pain control method:
Obtain 5-15cc of 1% lidocaine in a syringe (toxic dose of lidocaine without epinephrine is 5mg/kg)
Identify the fracture site and clean with antiseptic solution
Create a wheal of anesthetic at the area superficially above fracture site
Insert the needle tip into the wheal until the bone is felt while aspirating - aspiration of blood indicates correct placement in the fracture hematoma (make sure it is not pulsatile in the syringe or continually flowing to avoid systemic injection)
Inject lidocaine
Basic Principles of Fracture Reduction:
1. Longitudinal traction-countertraction
2. Recreate and exaggerate mechanism of injury while holding traction-countertraction
3. Alignment of the fractured ends while holding traction-countertraction. Then release traction to stabilize.
4. Post-reduction XR to verify alignment
4. Immobilization via Splinting/Casting
6. Reestablish neurovascular status
Here is a link to the full 3-minute video demonstrating a hematoma block, distal radius fracture reduction technique, and splinting:
https://youtu.be/cy6f7he2e4w?si=SVXqBZvoqmVVyAds
Make sure to provide the patient with orthopedic follow up, splint care instructions and return precautions as indicated.
Best,
Lekha Reddy