ClosedReduction,Traction,andCastingTechniquesDavidHak,MDOriginalAuthor:DanHorwitz,MD;March2004NewAuthor:DavidHak,MD;RevisedJanuary2006,October2008ClosedReductionPrinciplesAlldisplacedfracturesshouldbereducedtominimizesofttissuecomplications,includingthosethatrequireORIFUsesplintsinitiallyAllowforswellingAdequatelypadallbonyprominencesClosedReductionPrinciplesAdequateanalgesiaandmusclerelaxationarecriticalforsuccessReductionmaneuvermaybespecificforfracturelocationandpatternCorrect/restorelength,rotation,andangulationImmobilizejointaboveandbelowClosedReductionPrinciplesReductionmayrequirereversalofmechanismofinjury,especiallyinchildrenwithintactperiosteumWhenthebonebreaksbecauseofbending,thesofttissuesdisruptontheconvexsideandremainintactontheconcavesideFigurefromChapman’sOrthopaedicSurgery3rdEd.(RedrawnfromCharnleyJ.TheClosedTreatmentofCommonFractures,3rded.Baltimore:Williams&Wilkins,1963.)ClosedReductionPrinciplesLongitudinaltractionmaynotallowthefragmentstobedisimpactedandbroughtouttolengthifthereisanintactsoft-tissuehinge(typicallyseeninchildrenwhohavestrongperisoteumthatisintactononeside)FigurefromChapman’sOrthopaedicSurgery3rdEd.(RedrawnfromCharnleyJ.TheClosedTreatmentofCommonFractures,3rded.Baltimore:Williams&Wilkins,1963.)ClosedReductionPrinciplesReproductionofthemechanismoffracturetohookontheendsofthefractureAngulationbeyond90°isusuallyrequiredFigurefromChapman’sOrthopaedicSurgery3rdEd.(RedrawnfromCharnleyJ.TheClosedTreatmentofCommonFractures,3rded.Baltimore:Williams&Wilkins,1963.)ClosedReductionPrinciplesThreepointcontact(mold)isnecessarytomaintainclosedreductionRemovalofanyofthethreeforcesresultsinlossofreductionFigurefrom:RockwoodandGreen:FracturesinAdults,4thed,Lippincott,1996.ClosedReductionPrinciplesCastmustbemoldedtoresistdeformingforces“Straightcastsleadtocrookedbones”“Crookedcastsleadtostraightbones”AnesthesiaforClosedReductionHematomaBlock-aspiratehematomaandplace10ccofLidocaineatfracturesiteLessreliablethanothermethodsFastandeasyTheoreticallyconvertsclosedfracturetoopenfracturebutnodocumentedincreaseininfectionAnesthesiaforClosedReductionIVSedationVersed-0.5–1mgq3minutesupto5mgMorphine-0.1mg/kgDemerol-1-2mg/kgupto150mgBewareofpulmonarycomplicationswithdeepconscioussedation-consideranesthesiaserviceassistanceifthereisconcernPulseoximeterandcarefulmonitoringarerecommendedAnesthesiaforClosedReductionsBierBlock-superiorpainrelief,greaterrelaxation,lesspremedicationneededDoubletourniquetisinflatedonproximalarmandvenoussystemisfilledwithlocalLidocainepreferredforfastonsetVolume=40ccAdults2-3mg/kgChildren1.5mg/kgIftourniquetisdeflatedafter<40minutesthendeflatefor3secondsandre-inflatefor3minutes-repeattwiceWatchcloselyforcardiacandCNSsideeffects,especiallyintheelderlyCommonClosedReductionsDistalRadius

LongitudinaltractionLocalorregionalblockExaggeratedeformityPushforlengthandreversalofdeformityApplysplintorcastwith 3-pointmoldFigurefrom:RockwoodandGreen:FracturesinAdults,4thed,Lippincott,1996.CommonJointReductionsElbowDislocation-traction,flexion,anddirectmanualpushFiguresfromRockwoodandGreen,5thed.CommonJointReductionsShoulderDislocation

-relaxation,traction,gentlerotationifnecessaryFiguresfromRockwoodandGreen,5thed.CommonJointReductionsHipDislocationRelaxation,flexion,traction,adductionandinternalrotationGentleandatraumaticRelocationshouldbepalpableandpermitsignificantlyimprovedROM.Thisoftenrequiresverydeepsedation.FiguresfromRockwoodandGreen,5thed.SplintingNon-cicumferential–allowsforfurtherswellingMayuseplasterorprefabfiberglasssplints (plastermoldsbetter)CommonSplintingTechniques“Bulky”JonesSugar-tongCoaptationUlnargutterVolar/DorsalhandThumbspicaPosteriorslab(ankle)+/-UsplintPosteriorslab(thigh)SugarTongSplintSplintextendsaroundthedistalhumerustoproviderotationalcontrolPaddingshouldbeatleast3-4layersthickwithseveralextralayersattheelbow

MediallysplintendsintheaxillaandmustbewellpaddedtoavoidskinbreakdownLateralaspectofsplintextendsoverthedeltoidFigurefromRockwoodandGreen,4thed.HumeralShaftFractureCoaptationSplint

FractureBracingAllowsforearlyfunctionalROMandweightbearingReliesonintactsofttissuesandmuscleenvelopetomaintainalignmentandlengthMostcommonlyusedforhumeralshaftandtibialshaftfracturesConverttohumeralfracturebrace7-10daysafterfracture (i.e.whenfracturesiteisnottendertocompression).AllowsearlyactiveelbowROMFracturereductionmaintainedbyhydrostaticcolumnprincipleCo-contractionofmuscles-Snugbraceduringtheday-DonotrestelbowontablePatientmusttolerateasnugfitforbracetobefunctional

FigurefromRockwoodandGreen,4thed.CastingGoalofsemi-rigidimmobilizationwhileavoidingpressure/skincomplicationsOftenapoorchoiceinthetreatmentofacutefracturesduetoswellingandsofttissuecomplicationsGoodcasttechniquenecessarytoachievepredictableresultsCastingTechniquesStockinette-mayrequiretwodifferentdiameterstoavoidovertightorloosematerialCautionnottoliftlegbystockinette–stretchingthestockinettetootightaroundtheheelmaycasehighskinpressureCastingTechniquesToavoidwrinklesinthestockineete,cutalongtheconcavesurfaceandoverlaptoproduceasmoothcontourFigurefromChapman’sOrthopaedicSurgery3rdEd.CastingTechniquesCastpaddingRolldistaltoproximal50%overlap2layersminimumExtrapaddingatfibularhead,malleoli,patella,andolecranonFigurefromChapman’sOrthopaedicSurgery3rdEd.Plastervs.FiberglassPlasterUsecoldwatertomaximizemoldingtimeFiberglass

Moredifficulttomoldbutmoredurableandresistanttobreakdown

Generally2-3timesstrongerforanygiventhicknessWidthCastingmaterialsareavailableinvariouswidths6inchforthigh3-4inchforlowerleg3-4inchforupperarm2-4inchforforearmFigurefromChapman’sOrthopaedicSurgery3rdEd.AvoidmoldingwithanythingbuttheheelsofthepalminordertoavoidpressurepointsMoldappliedtoproducethreepointfixationCastMoldingBelowKneeCastSupportmetatarsalheadsAnkleinneutral–flexkneetorelaxgastrocEnsurefreedomoftoesBuildupheelforwalkingcasts-fiberglassmuchpreferredfordurabilityPaddingforfibularheadandplantaraspectoffootPaddedfibularheadFlexedkneeNeutralanklepositionToesfreeAssistantorfootstandrequiredtomaintainanklepositionFigurefrom:BrownerandJupiter:SkeletalTrauma,2nded,Saunders,1998.ShortLegCastWhenworkingalone,thepatientcanhelpmaintainproperanklepositionbyholdingontoamuslinbandageplacedbeneaththetoesFigurefromChapman’sOrthopaedicSurgery3rdEd.AboveKneeCastApplybelowkneefirst(thinlayerproximally)Flexknee5-20degreesMoldsupracondylarfemurforimprovedrotationalstabilityApplyextrapaddinganteriortopatellaAnteriorpaddingSupportlowerleg/castExtendtoglutealcreaseFigurefrom:BrownerandJupiter:SkeletalTrauma,2nded,Saunders,1998.ForearmCasts&SplintsMCPjointsshouldbefreeDonotgopastproximalpalmarcreaseThumbshouldbefreetobaseofMCOppositionofthumbtolittlefingershouldbeunobstructedxxExamples-PositionofFunctionAnkle-Neutraldorsiflexion–NoEquinusHand-MCPsflexed70–90o,IPsinextension70-90degreesFigurefromRockwoodandGreen,5thed.CastWedgingEarlyfollow-upx-raysarerequiredtoensurereductionisnotlostCastmaybe“wedged”tocorrectreductionDeformityisdrawnoutoncastCastiscutcircumferentiallyCastiswedgedtocorrectdeformityandtheover-wrappedExampleofcastwedgingtocorrectlossofreductionofapediatricdistalbothboneforearmfracture.FromHalanskiM,NoonanKJ.JAmAcadOrthopSurg.2008.ComplicationsofCasts&SplintsLossofreductionPressurenecrosis–mayoccurasearlyas2hoursTightcast

compartmentsyndrome Univalving=30%pressuredrop Bivalving=60%pressuredropAlsoneedtocutcastpaddingComplicationsofCasts&SplintsThermalInjury-avoidplaster>10ply,water>24°C,unusualwithfiberglassCu