What is the recommended approach for the process of reduction in fracture management?

Fracture Reduction: Recommended Approach

The optimal approach to fracture reduction depends on fracture stability and displacement: perform closed reduction for stable, minimally displaced fractures where anatomic alignment can be achieved and maintained with immobilization, but proceed directly to open reduction and internal fixation for displaced unstable fractures where closed methods cannot achieve or maintain proper alignment. 1

Decision Algorithm for Reduction Method Selection

Closed Reduction Indications

• Use closed reduction for stable, non-displaced, or minimally displaced fractures where anatomic alignment can be restored and maintained with casting or splinting 1
• Both finger-trap traction and manual manipulation achieve similar reduction quality (87% satisfactory reduction rate) and similar rates of maintaining alignment 2
• Closed reduction successfully reduces the majority of fractures initially, though substantial redisplacement during cast immobilization is common (only 27-32% maintain acceptable alignment at 5 weeks) 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
• For distal radius fractures specifically, the American Academy of Orthopaedic Surgeons suggests surgical fixation when post-reduction parameters show radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement 3
• Open reduction provides direct visualization and controlled manipulation of fracture fragments, which is especially important for complex fractures like femoral neck fractures 4

Critical Pre-Reduction Planning

Before attempting reduction, plan where to apply forces, by what means, and how to position both the patient and imaging equipment 5. This preoperative planning phase includes:

• Determining the optimal patient positioning for the specific fracture type 5
• Planning C-arm positioning for intraoperative fluoroscopic control 5
• Strategizing how to temporarily maintain reduction for x-ray verification of axis, rotation, and length before definitive fixation 5

Immediate Post-Reduction Management

Pain Control

• Provide appropriate pain relief immediately and throughout the entire treatment period, as inadequate pain management leads to poor outcomes 1
• For patients requiring surgery, ensure multimodal analgesia postoperatively 6

Immobilization and Monitoring

• Ensure proper immobilization technique appropriate to the fracture type and reduction method 1
• Obtain follow-up imaging at regular intervals to detect any loss of reduction early 1, 7
• Close monitoring is essential because insufficient follow-up leads to missed complications 1

Early Mobilization Protocol

Begin finger motion immediately after casting or surgery for upper extremity fractures to prevent edema and stiffness 1. The rehabilitation timeline includes:

• Introduce physical training and muscle strengthening early in the post-fracture period 1, 7, 6
• Progress to aggressive mobilization once the fracture shows adequate healing on imaging 1
• Continue balance training and fall prevention strategies long-term 7, 6

Critical Pitfall to Avoid

Delayed mobilization results in stiffness and suboptimal functional recovery—starting range-of-motion exercises late is a major preventable error 1

Special Considerations for Vascular Compromise

Pediatric Supracondylar Fractures

• Perform emergent closed reduction for displaced fractures with decreased hand perfusion 3
• If absent wrist pulses and underperfusion persist after reduction and pinning, perform open exploration of the antecubital fossa 3
• The degree of vascular compromise varies from absent pulses with some perfusion to a completely pale hand with nerve deficits—practitioner judgment is essential in determining timing and location of reduction 3

Secondary Fracture Prevention (Age ≥50 Years)

For all patients aged 50 and over with any fragility fracture:

• Systematically evaluate every patient for subsequent fracture risk 1, 7
• 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% 1
• Initiate pharmacological treatment with alendronate or risedronate as first-line agents for high-risk patients 1
• Do not use high-pulse dosages of vitamin D, as these increase fall risk rather than prevent it 1

Age-Specific Considerations

Patients Over 55 Years

The American Academy of Orthopaedic Surgeons found no demonstrated difference between casting and surgical fixation in patients aged >55 years with distal radius fractures, making this an inconclusive recommendation that requires individualized clinical judgment 3

Elderly Hip Fracture Patients

Provide orthogeriatric comanagement to improve functional outcomes and reduce length of hospital stay and mortality 3. The joint care model between geriatrician and orthopedic surgeon on a dedicated orthogeriatric ward achieves the shortest time to surgery, shortest inpatient stay, and lowest mortality rates 3