What is the process for anabolic reduction and immobilization?

Anabolic Reduction and Immobilization Process

Rigid immobilization is strongly recommended over removable splints for the management of displaced distal radius fractures to maintain proper alignment and promote optimal healing. 1

Understanding Anabolic Reduction and Immobilization

Anabolic reduction and immobilization is a treatment approach that combines:

1. Fracture reduction (realignment of bone fragments)
2. Immobilization of the affected area
3. Consideration of metabolic factors to minimize muscle loss

The process involves several key steps:

Step 1: Fracture Reduction

• Perform closed manipulation to realign displaced bone fragments
• Confirm adequate alignment with radiographic imaging
• For intra-articular fractures, arthroscopic evaluation is an option to improve diagnostic accuracy 1

Step 2: Immobilization Selection

For displaced fractures:

• Use rigid immobilization (cast) rather than removable splints 1
• For minimally displaced fractures, removable splints may be an option 1

The choice of immobilization depends on fracture type:

• Displaced fractures: Rigid cast immobilization (circumferential casting)
• Minimally displaced fractures: Removable splints may be sufficient

Step 3: Duration of Immobilization

• Maintain immobilization for 3-5 weeks based on fracture type and healing progress
• Follow with radiographic evaluation at 3 weeks and at cessation of immobilization 1

Metabolic Considerations During Immobilization

Immobilization causes significant metabolic changes that must be addressed:

• Muscle loss: Seven days of bedrest can result in 1 kg loss of lean leg muscle mass, particularly in older adults 1
• Metabolic changes: Decreased basal energy expenditure, reduced insulin sensitivity, and anabolic resistance to protein nutrition 1
• Strength loss: Initial loss of strength occurs rapidly during immobilization and plateaus after about 30 days 1

Strategies to Minimize Muscle Loss During Immobilization

1. Nutritional interventions:

   • Increase protein intake to exceed 1 g/kg body weight/day 1
   • Consider essential amino acid (EAA) supplementation 1
   • Beta-hydroxy-beta-methylbutyrate (HMB) supplementation has shown significant reduction in muscle loss during bedrest 1

2. Activity modifications:

   • Implement resistance exercise for non-immobilized body parts 1
   • Maintain mobility of unaffected joints

Special Considerations

For Elderly Patients

• Older adults experience more pronounced decreases in ambulatory function and ability to complete daily activities after immobilization 1
• Consider anabolic agents like teriparatide for very high-risk patients with osteoporosis to counteract immobilization-induced bone loss 2
• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) intake 1

For Patients with Diabetes and Neuropathy

• Non-removable devices are preferred over removable ones for patients with Charcot neuro-osteoarthropathy as they show shorter time to remission 1
• Monitor skin integrity closely as devices can result in skin breakdown in patients with loss of protective sensation 1

Common Pitfalls and Caveats

1. Non-adherence to immobilization: The main disadvantage of removable devices is potential non-adherence, which may lead to development/progression of deformity and delayed healing 1

2. Inadequate reduction: Failure to achieve proper alignment initially may necessitate surgical intervention

3. Prolonged immobilization: Extended immobilization periods can lead to:

   • Muscle atrophy
   • Joint stiffness
   • Decreased bone mineral density

4. Insufficient nutritional support: Inadequate protein intake during immobilization accelerates muscle loss 1

5. Skin complications: Improperly applied casts or splints can cause pressure sores or skin breakdown, particularly in patients with sensory deficits 1

By following these principles of anabolic reduction and immobilization, you can optimize fracture healing while minimizing complications and functional decline.