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Sunday, 11 September 2011


Principles of fracture < Reduction >

This first principle must be qualified by the words ‘if necessary’. In many fractures reduction is unnecessary, either because there is no displacement or
because the displacement is immaterial to the final result. A considerable experience of fractures is needed before one can say with confidence
whether or not reduction is advisable in a given case. If it is judged that perfect
function can be restored without undue loss of time, despite some uncorrected
displacement of the fragments, there is clearly no object in striving for perfect
anatomical reduction. Indeed, meddlesome intervention may sometimes be
detrimental, especially if it entails open operation.
To take a simple example, there is no object in striving to replace perfectly
the broken fragments of a child’s clavicle, because normal function and
appearance will be restored without any intervention; the same applies to most fractures of the clavicle in adults. Likewise there is nothing to be gained instriving for perfect reduction of a fracture of the neck of the humerus in anelderly person—an ideal that may demand open operation for its attainment—
when good or better results may be expected from conservative treatmentdespite imperfect reduction.
In general, it may be said that imperfect apposition of the fragments can be
accepted much more readily than imperfect alignment (Fig. 3.1). For example,
in the shaft of the femur a loss of contact of half a diameter might be acceptable
whereas an angular deformity of 20º would usually demand an attempt at
improvement. When a joint surface is involved in a fracture, the articular
fragments must always be restored as nearly as possible to normal, to lessen
the risk of subsequent osteoarthritis.

When reduction is decided upon it may be carried out in three ways:
1. by closed manipulation
2. by mechanical traction with or without manipulation
3. by open operation.
Manipulative reduction
Closed manipulation is the standard initial method of reducing most common
fractures. It is usually carried out under general anaesthesia, but local or
regional anaesthesia is sometimes appropriate. The technique is simply to
grasp the fragments through the soft tissues, to disimpact them if necessary,
and then to adjust them as nearly as possible to their correct position.
Reduction by mechanical traction
When the contraction of large muscles exerts a strong displacing force, some
mechanical aid may be necessary to draw the fragments out to the normal
length of the bone. This particularly applies to fractures of the shaft of the
femur, and to certain types of fracture or displacement of the cervical spine.
Principles of fracture treatment
Fig. 3.1 Imperfect apposition (left) may
often be accepted, whereas malalignment
of more than a few degrees must usually
be corrected.
Often acceptable Seldom acceptable
Ch03-F10297.qxd  3/27/07  11:26 AM  Page 31Traction may be applied either by weights or by a screw device, and the aim
may be to gain full reduction rapidly at one sitting with anaesthesia, or to rely
upon gradual reduction by prolonged traction without anaesthesia.
Operative reduction
When an acceptable reduction cannot be obtained, or maintained, by these
conservative methods, the fragments are reduced under direct vision at open
operation. Open reduction may also be required for some fractures involving
articular surfaces, or when the fracture is complicated by damage to a nerve or
artery. When operative reduction is resorted to, the opportunity should always
be taken to fix the fragments internally to ensure that the position is maintained

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