ortho 03 principle of closed reduction in fracture and dislocation

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ortho 03 principle of closed reduction in fracture and dislocation

  1. 1. Principle of closed reduction in fracture and dislocation Department of Orthopaedic Surgery Faculty of Medicine Siriraj Hospital Mahidol University
  2. 2. Principle of closed reduction <ul><li>Recognition the pathologies </li></ul><ul><ul><li>Associated injury </li></ul></ul><ul><ul><li>Deforming forces </li></ul></ul><ul><li>Adequate anesthesia </li></ul><ul><li>Good team </li></ul><ul><li>Good technique </li></ul><ul><li>Acceptable reduction </li></ul><ul><li>Retention </li></ul>
  3. 3. Recognizing the pathology <ul><li>Type of fracture/dislocation </li></ul><ul><li>Deformities (including the deforming forces) </li></ul>
  4. 4. Signs and symptoms of fracture/dislocation <ul><li>Pain </li></ul><ul><li>Swelling </li></ul><ul><li>Tenderness </li></ul><ul><li>Deformities </li></ul><ul><li>Limit ROM </li></ul><ul><li>Stepping </li></ul><ul><li>Crepitus </li></ul>
  5. 5. Typical fractures
  6. 6. Stress-strain curve
  7. 7. Mode of failure <ul><li>Tension </li></ul>
  8. 8. Mode of failure <ul><li>Compression </li></ul>
  9. 9. Mode of failure <ul><li>Shear </li></ul>
  10. 10. Mode of failure <ul><li>Bending </li></ul><ul><ul><li>Tension </li></ul></ul><ul><ul><li>Compression </li></ul></ul>
  11. 11. Mode of failure <ul><li>Torsion </li></ul><ul><ul><li>Tension </li></ul></ul><ul><ul><li>Compression </li></ul></ul><ul><ul><li>Shear </li></ul></ul>
  12. 12. Mode of failure <ul><li>Crush </li></ul><ul><ul><li>Tension </li></ul></ul><ul><ul><li>Compression </li></ul></ul><ul><ul><li>Shear </li></ul></ul>
  13. 13. Know the classification
  14. 14. Anesthesia <ul><li>Local </li></ul><ul><ul><li>Hematoma block </li></ul></ul><ul><li>Regional block </li></ul><ul><li>General </li></ul><ul><ul><li>General anesthesia </li></ul></ul><ul><ul><li>Sedation using morphine, benzodiazepine </li></ul></ul>
  15. 15. Regional/sedation
  16. 16. Reduction technique with or without assistances
  17. 17. Principle of reduction <ul><li>Traction based technique </li></ul><ul><li>Increase deformities </li></ul><ul><li>Reverse mechanisms </li></ul><ul><li>Forces using: </li></ul><ul><ul><li>Constance </li></ul></ul><ul><ul><li>Shaking for muscle relaxation </li></ul></ul>
  18. 18. Sequences of fracture reduction <ul><li>Traction </li></ul><ul><li>Increase deformity </li></ul><ul><li>Reverse deformity </li></ul><ul><li>3 point bending </li></ul>
  19. 19. Ligamentotaxis <ul><li>Tension applied across a fracture site </li></ul><ul><li>Realign the fracture fragments by the surrounding intact soft tissue </li></ul><ul><li>Soft tissue hinge eg. Periostium </li></ul><ul><li>Perform early after injury </li></ul>
  20. 20. Shoulder dislocation <ul><li>Siriraj reduction technique </li></ul><ul><li>Usually no need the anesthesia </li></ul><ul><li>Supine position </li></ul><ul><li>Gentle longitudinal traction and external rotation </li></ul><ul><li>Gradual abduction </li></ul><ul><li>Usually reduce around 120 deg of abduction </li></ul>
  21. 21. Traction based
  22. 22. Hip dislocation (Allis method)
  23. 23. Acceptable reduction? <ul><li>Mainly focus on fracture not dislocation </li></ul><ul><li>Joint must be congruent and concentric </li></ul>
  24. 24. Acceptable reduction? <ul><li>Functional concern </li></ul><ul><li>Mechanics </li></ul><ul><li>Shortening </li></ul><ul><li>Apposition </li></ul><ul><li>Sagital, coronal plane malalignment </li></ul><ul><li>Axial malalignment is not accepted (rotation) </li></ul>
  25. 25. Acceptable reduction? <ul><li>More acceptable in: </li></ul><ul><li>Young age eg. Bayonette </li></ul><ul><li># Far from the joint </li></ul><ul><li>Compensation </li></ul><ul><li>Less acceptable in: </li></ul><ul><li># Near the joint </li></ul><ul><li>Intraarticular involvement </li></ul>
  26. 26. Immobilization alone (no reduction needed) <ul><li>Non displaced fracture </li></ul><ul><li>Isolated fibular fracture </li></ul><ul><li>Acceptable alignment </li></ul><ul><ul><li>Pediatric # shaft of femur </li></ul></ul><ul><ul><li>Bayonett apposition </li></ul></ul>
  27. 27. High failure rate of reduction in: <ul><li>Avulsion fracture </li></ul><ul><li>Unstable fracture </li></ul><ul><ul><li>Displaced fracture both bone of forearm </li></ul></ul><ul><ul><li>But realign the fracture </li></ul></ul><ul><ul><li>Except # BB in children </li></ul></ul><ul><li>Fracture that won’t heal </li></ul><ul><ul><li>Fracture neck of femur in elderly </li></ul></ul>
  28. 28. Common fracture in upper extremities <ul><li>Distal end of radius </li></ul><ul><li>Boxer’s (neck of 5 th MCB) </li></ul><ul><li>Humerus </li></ul><ul><ul><li>Neck of humerus </li></ul></ul><ul><ul><li>Shaft </li></ul></ul><ul><ul><li>Supracondyle </li></ul></ul><ul><li>Clavicle </li></ul>
  29. 31. Common fractures in lower extremities <ul><li>Common Fracture in Adult </li></ul><ul><li>Femoral shaft </li></ul><ul><li>Tibia and fibular </li></ul><ul><li>Ankle </li></ul>
  30. 33. Common fractures in lower extremities <ul><li>Common Fracture in Elderly </li></ul><ul><li>Femoral neck </li></ul><ul><li>Intertrochanteric </li></ul>
  31. 35. Fracture of the spine <ul><li>C-spine </li></ul><ul><ul><li>Odontoid </li></ul></ul><ul><ul><li>Compression </li></ul></ul><ul><ul><li>Burst </li></ul></ul><ul><ul><li>Fracture dislocation </li></ul></ul><ul><li>Thoracolumbar </li></ul><ul><ul><li>Compression </li></ul></ul><ul><ul><li>Burst </li></ul></ul><ul><ul><li>Fracture dislocation </li></ul></ul>
  32. 38. Commonly missed conditions <ul><li>Scaphoid fracture </li></ul><ul><li>Perilunate dislocation </li></ul><ul><li>Forearm fracture with radioulnar joint dislocation </li></ul><ul><li>Pediatric fracture around the elbow </li></ul><ul><ul><li>Supracondyle </li></ul></ul><ul><ul><li>Lateral condyle </li></ul></ul><ul><ul><li>Medial condyle </li></ul></ul><ul><li>Nerve injury eg. Axillary nerve </li></ul><ul><li>Occult fracture </li></ul><ul><li>Obese patients </li></ul><ul><li>Uncommon injuries eg. Posterior shoulder dislocation </li></ul><ul><li>Impact fracture neck of femur </li></ul>
  33. 39. Occult fracture <ul><li>Not visible in an x-ray within 1-2 day of injury </li></ul><ul><li>Become visible </li></ul><ul><ul><li>Within 3-4weeks </li></ul></ul><ul><ul><li>At the time that healing </li></ul></ul>
  34. 40. Obese
  35. 41. Posterior shoulder dislocation
  36. 42. Management problems? <ul><li>Fracture dislocation </li></ul><ul><li>Complex dislocation eg. MCP joint </li></ul><ul><li>Fracture of necessity eg. Monteggia’s, Galeazzi’s </li></ul>
  37. 43. Fracture dislocation
  38. 44. Complex dislocation
  39. 45. Monteggia fracture
  40. 46. Fracture healing <ul><li>Clinical union </li></ul><ul><li>Timing </li></ul><ul><li>No false movement </li></ul><ul><li>No local tenderness of #site </li></ul><ul><ul><li>Axial loading </li></ul></ul><ul><ul><li>Bending </li></ul></ul><ul><ul><li>Rotation </li></ul></ul><ul><li>Radiographic union </li></ul><ul><li>Crossing trabeculae </li></ul><ul><li>Absent fracture line </li></ul>

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