What is the recommended approach for reducing a fracture?

Fracture Reduction: Recommended Approach

The approach to fracture reduction depends critically on fracture stability and displacement: stable or minimally displaced fractures should undergo closed reduction with immobilization, while unstable or significantly displaced fractures require open reduction and internal fixation to optimize functional outcomes and prevent complications. 1

Decision Algorithm for Reduction Method

Closed Reduction Indications

• Perform closed reduction for stable, non-displaced, or minimally displaced fractures where anatomic alignment can be achieved and maintained with casting or splinting 1
• Closed reduction is appropriate when post-reduction imaging demonstrates acceptable alignment parameters specific to the fracture location 2
• For lateral condylar humeral fractures in children, closed reduction with internal fixation is effective when residual displacement is ≤2 mm; if displacement exceeds 2 mm after closed reduction, proceed immediately to open reduction 2

Open Reduction Indications

• Proceed directly to open reduction and internal fixation for displaced unstable fractures, particularly when closed reduction cannot achieve or maintain anatomic alignment 1, 3
• Open reduction is mandatory for fractures with significant displacement that correlates with poor functional outcomes if left unreduced 3
• Satisfactory operative reduction is the single factor that correlates best with satisfactory clinical results, making anatomic reduction the primary goal 3

Immediate Post-Reduction Management

Pain Control and Stabilization

• Provide appropriate pain relief immediately and throughout the treatment period, as inadequate pain management leads to poor outcomes 1, 4
• Ensure proper immobilization technique appropriate to the fracture type and reduction method 1

Early Mobilization Protocol

• Begin finger motion immediately after casting or surgery for upper extremity fractures to prevent edema and stiffness 5, 4
• Start aggressive finger and hand motion exercises as soon as immobilization is discontinued 5
• Introduce physical training and muscle strengthening early in the postfracture period 5, 4

Monitoring and Follow-Up

Radiographic Surveillance

• Obtain follow-up imaging at regular intervals to ensure proper healing and detect any loss of reduction early 4
• Delayed detection of complications occurs when follow-up imaging is insufficient 4

Rehabilitation Progression

• Progress to aggressive mobilization once the fracture shows adequate healing on imaging 4
• Continue long-term balance training and multidimensional fall prevention to reduce subsequent fracture risk 5

Critical Pitfalls to Avoid

• Do not accept inadequate reduction: Satisfactory operative reduction directly correlates with clinical outcomes, so anatomic alignment must be the standard 3
• Avoid delayed mobilization: Starting range-of-motion exercises late results in stiffness and suboptimal functional recovery 4
• Do not use high-pulse dosages of vitamin D for fracture patients, as these increase fall risk rather than prevent it 5
• Ensure close monitoring with imaging, as insufficient follow-up leads to missed complications 4

Secondary Fracture Prevention (Age ≥50)

• Systematically evaluate every patient aged 50 years and over for subsequent fracture risk after any fragility fracture 5
• Prescribe calcium 1000-1200 mg/day combined with vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20% 5
• Initiate pharmacological treatment with alendronate or risedronate as first-line agents for patients at high risk of subsequent fractures 5
• Coordinate care between surgeons, rheumatologists/endocrinologists, and general practitioners through a designated local lead 5