What is the proper procedure for performing a wrist reduction?

Proper Procedure for Performing a Wrist Reduction

Wrist reduction should be performed using a standardized approach with adequate analgesia, proper positioning, appropriate traction, and post-reduction immobilization to restore normal anatomical alignment while minimizing complications. 1

Initial Assessment and Imaging

• Obtain radiographs with a minimum of 3 views before attempting reduction:

  • Posteroanterior (PA)
  • Lateral
  • 45° semipronated oblique 1, 2
  • Consider a fourth view (semisupinated oblique) for better visualization 2

• Assess for:

  • Fracture pattern and displacement
  • Intra-articular involvement
  • Neurovascular status (especially important with vascular compromise)
  • Associated soft tissue injuries

Reduction Procedure

1. Analgesia and Relaxation

   • Administer appropriate analgesia:
     • Consider procedural sedation for complex reductions
     • Local hematoma block (10-15 mL of 1% lidocaine without epinephrine)
     • Nitrous oxide may be used as an adjunct 3

2. Positioning and Technique

   • Position the patient sitting with elbow flexed at 90°
   • Assistant stabilizes the proximal forearm
   • Apply longitudinal traction to the hand in line with the forearm
   • For distal radius fractures:
     • Apply pressure with thumbs over the dorsal distal fragment while supporting volar aspect with fingers
     • Correct any angulation by applying appropriate counter-pressure
   • For carpal dislocations:
     • Apply firm, steady traction while manipulating the displaced carpal bones back into position

3. Confirmation of Reduction

   • Assess clinically for:
     • Improved alignment
     • Restoration of normal contour
     • Improved range of motion (if appropriate)
     • Neurovascular status (especially important with pre-reduction vascular compromise)
   • Obtain post-reduction radiographs to confirm adequate alignment

Post-Reduction Management

1. Immobilization

   • Apply well-padded sugar-tong or volar splint in slight wrist extension
   • Ensure splint does not restrict finger motion
   • Instruct patient to move fingers regularly through complete range of motion to minimize stiffness 2

2. Follow-up

   • Arrange orthopedic follow-up within 5-7 days
   • Obtain repeat radiographs to ensure maintenance of reduction
   • Typical immobilization duration: 4-6 weeks 1

Special Considerations

• Vascular Compromise: In cases with absent wrist pulses or decreased hand perfusion, emergent reduction should be performed to restore blood flow 2, 1

• Failed Closed Reduction: Consider:

  • Repeat attempt with improved analgesia/sedation
  • Orthopedic consultation for possible surgical intervention
  • CT imaging to better characterize the fracture pattern 1

• Unstable Fractures: Fractures with the following features may require surgical fixation:

  • Intra-articular fractures with >2mm step-off
  • Coronally oriented fracture lines
  • Die-punch depression
  • More than three articular fragments 1

Potential Complications

• Inadequate reduction leading to malunion
• Neurovascular injury
• Complex regional pain syndrome
• Stiffness (minimize by encouraging early finger motion) 2
• Compartment syndrome (rare but requires emergent intervention)

By following this systematic approach to wrist reduction, clinicians can optimize outcomes while minimizing complications for patients with wrist injuries requiring reduction.