This document discusses techniques for closed reduction and casting of fractures. It notes that displaced fractures should be reduced to minimize soft tissue complications. Adequate analgesia and muscle relaxation are critical for successful reduction. The reduction maneuver depends on the fracture location and pattern, and must restore proper length, rotation, and angulation. Longitudinal traction alone may not allow reduction if an intact soft tissue hinge is present. Reproduction of the fracture mechanism is often needed, sometimes requiring angulation beyond 90 degrees. A well-molded three-point cast is necessary to maintain reduction, and a cast with a cast index below 0.7 has been shown to help prevent redisplacement of distal forearm fractures.

1. RE
BAGIAN ORTOPEDI &TRAUMATOLOGI FAKULTAS KEDOKTERAN UNHAS MAKASSAR
3 juli 2018

2. • All 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
Hak D. Closed Reduction, Traction, and Casting
Techniques.OTA. 2008

3. • Adequate analgesia and muscle relaxation are criti
cal for success
• Reduction maneuver may be specific for fracture l
ocation and pattern
• Correct/restore length, rotation, and angulation
• Immobilize joint above and below
Hak D. Closed Reduction, Traction, and Casting
Techniques.OTA. 2008

4. • Reduction may require reversal of mechanism of injury, especially in children with intact periosteum
• When the bone breaks because of bending, the soft tissues disrupt on the convex side and remain intact on t
he concave side
Figure from Chapman’s Orthopaedic Surgery 3rd Ed. (R
edrawn from Charnley J. The Closed Treatment of Com
mon Fractures, 3rd ed. Baltimore: Williams & Wilkins,
1963.)
Hak D. Closed Reduction, Traction, and Casting
Techniques.OTA. 2008

5. • Longitudinal traction may not allow the fragments to be disimpacted and broug
ht 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 Chapman’s Orthopaedic Surgery 3rd Ed. (R
edrawn from Charnley J. The Closed Treatment of Com
mon Fractures, 3rd ed. Baltimore: Williams & Wilkins,
1963.)
Hak D. Closed Reduction, Traction, and Casting
Techniques.OTA. 2008

6. • Reproduction of the mechanism of fracture to hook on the ends of the fracture
• Angulation beyond 90° is usually required
Figure from Chapman’s Orthopaedic Surger
y 3rd Ed. (Redrawn from Charnley J. The Cl
osed Treatment of Common Fractures, 3rd e
d. Baltimore: Williams & Wilkins, 1963.)
Hak D. Closed Reduction, Traction, and Casting
Techniques.OTA. 2008

7. Three point contact (mold)
is necessary to maintain c
losed reduction
Removal of any of the three
forces results in loss of reduction
Figure from: Rockwood and Green: Fractures i
n Adults, 4th ed, Lippincott, 1996.

9. • Cast must be molded to resist deforming forces
– “Straight casts lead to crooked bones”
– “Crooked casts lead to straight bones”
Hak D. Closed Reduction, Traction, and Casting
Techniques.OTA. 2008

10.  Most common complication of the closed method of is
redisplacement within the cast.
 Rates of redisplacement 12% - 34%
 The redisplacement factors  fracture and surgeon
related. (quality of manipulation and cast application)
 To achieve a high quality casting
 an adequate reduction + good plaster application technique.
 application of a well moulded cast with three-point bending or
appropriate interosseous mould
Basavarajanna.Study of cast index in middle third fractures of both bones of
forearm in children. International Journal of Orthopaedics Sciences.2017

11.  Objective criteria for measuring the quality of
cast
 Cast index
 Gap index,
 Padding index
 Canterbury index.
Basavarajanna.Study of cast index in middle third fractures of both bones of
forearm in children. International Journal of Orthopaedics Sciences.2017

12.  cast index suggested byChess et al 1994
 Chess DG, Hyndman JC, Leahey JL, Brown
DCS, SinclairAM. Short arm plaster cast for
distal pediatric forearm fractures. J Pediatr
Orthop 1994; 14:211-213
Basavarajanna.Study of cast index in middle third fractures of both bones of
forearm in children. International Journal of Orthopaedics Sciences.2017

13.  conducted a study in which all distal one third
fractures requiring reduction were included if
the distal radial physis was open
 a short-arm cast was used
 pre-reduction, post-reduction
 three week follow-up radiographs were
available for review.
Basavarajanna.Study of cast index in middle third fractures of both bones of
forearm in children. International Journal of Orthopaedics Sciences.2017

14.  Cast Index (CI), defined as ratio of inner
diameter of the cast in lateral view to that in
AP view was measured at the fracture site in all
the radiographs.
 The CI is a simple reliable radiographic
measurement to predict and analyze the
redisplacement of distal forearm fractures in
children

15.  This original paper describing the
recommended a CI of <0.7
 Traditionally, CI has been used for distal
forearm fractures but there is little evidence to
determine how effective CI is at judging the
quality of cast molding in proximal forearm
fractures
Basavarajanna.Study of cast index in middle third fractures of both bones of
forearm in children. International Journal of Orthopaedics Sciences.2017

16.  Obtaining a low cast index near 0.7 is possible
in distal forearm fractures but difficult in
middle and proximal fractures as the soft
tissue envelop increases as we go more
proximally
Basavarajanna.Study of cast index in middle third fractures of both bones of
forearm in children. International Journal of Orthopaedics Sciences.2017