Fractures are common injuries that affect the skeletal system and require appropriate management to restore function and prevent complications. Depending on the type, location, and severity of the fracture, different methods of treatment may be indicated. One of these methods is closed reduction, which is a nonsurgical procedure to set (reduce) a broken bone without cutting the skin open¹. This article will discuss the principles and techniques of closed reduction, as well as its indications, benefits, and risks.

What is Closed Reduction?

Closed reduction is a procedure that involves manipulating the fractured bone segments back into their normal anatomical alignment without exposing them through an incision². It is usually performed under local anesthesia, sedation, or general anesthesia, depending on the patient’s condition and preference¹. The goal of closed reduction is to restore the length, rotation, and angulation of the bone, as well as to minimize soft tissue damage and provide patient comfort³.

Closed reduction can be performed by an orthopedic surgeon, an emergency physician, or a primary care provider who has experience in this procedure¹. It is often done in an emergency department or an orthopedic clinic, and usually takes less than an hour to complete². After the procedure, the reduced fracture is immobilized with a cast, splint, or brace to prevent displacement and promote healing¹.

When is Closed Reduction Indicated?

Closed reduction is indicated for mildly displaced fractures that do not involve significant comminution, articular involvement, or neurovascular compromise². These include:

• Simple fractures of the clavicle, humerus, radius, ulna, femur, tibia, fibula, metacarpals, metatarsals, and phalanges² .
• Some fractures of the scaphoid, lunate, capitate, hamate, talus, calcaneus, and navicular.
• Some fractures of the distal radius (Colles’ fracture), distal humerus (supracondylar fracture), proximal humerus (greater tuberosity fracture), proximal femur (subcapital fracture), and distal tibia (pilon fracture).

Closed reduction is not indicated for fractures that are:

• Severely displaced or angulated².
• Comminuted or segmental².
• Intra-articular or involving joint surfaces².
• Associated with neurovascular injury or compartment syndrome².
• Unstable or prone to redisplacement².

These fractures require open reduction and internal fixation (ORIF), which is a surgical procedure that involves making an incision over the fracture site and using metal plates, screws, rods, wires, or nails to stabilize the bone fragments.

How is Closed Reduction Performed?

The following are the general steps of performing closed reduction for a fracture³ :

1. Fracture distraction: The provider applies axial traction to the fractured limb to pull the bone fragments apart and disengage them from each other. This reduces the friction between the bone ends and facilitates their alignment.
2. Fracture disengagement: The provider rotates the fracture in the opposite direction of the original deformity to undo the mechanism of injury. This helps to correct any rotational malalignment and restore the normal anatomy of the bone.
3. Fracture reapposition: The provider applies gentle pressure to the sides of the fracture to push the bone fragments back into their normal position. This helps to correct any length or angulation deformity and achieve a satisfactory reduction.
4. Fracture release: Once the provider confirms that the fracture is adequately reduced by palpation and radiography, they release the traction and immobilize the fracture with a cast, splint, or brace. This prevents any displacement or loss of reduction during healing.

The specific techniques of closed reduction may vary depending on the location and type of fracture. For example:

• For a Colles’ fracture (a distal radius fracture with dorsal angulation), the provider may use a wrist hyperextension maneuver to reduce the fracture by applying pressure over the dorsal aspect of the distal fragment while flexing the wrist.
• For a supracondylar fracture (a distal humerus fracture with anterior angulation), the provider may use an elbow flexion maneuver to reduce the fracture by applying pressure over the olecranon while flexing the elbow.
• For a subcapital fracture (a proximal femur fracture with medial displacement), the provider may use an abduction-external rotation maneuver to reduce the fracture by applying traction and abduction to the affected leg while externally rotating the hip.

What are the Benefits of Closed Reduction?

Closed reduction has several advantages over open reduction, such as:

• Less invasive: Closed reduction does not require making an incision or exposing the fracture site, which reduces the risk of infection, bleeding, and scarring².
• Less painful: Closed reduction causes less tissue damage and inflammation, which reduces the pain and swelling after the procedure².
• Faster recovery: Closed reduction allows for earlier mobilization and rehabilitation of the affected limb, which improves the functional outcome and reduces the risk of complications such as stiffness, contracture, and osteoporosis².
• Lower cost: Closed reduction is less expensive than open reduction, as it does not require surgical equipment, materials, or hospitalization².

What are the Risks of Closed Reduction?

Closed reduction is generally a safe and effective procedure, but it may have some potential complications, such as:

• Inadequate or loss of reduction: The fracture may not be reduced properly or may become displaced again after the procedure, which may compromise the healing and function of the bone². This may require a repeat closed reduction or an open reduction with internal fixation.
• Neurovascular injury: The fracture or the reduction maneuver may damage the nerves or blood vessels near the fracture site, which may cause numbness, tingling, weakness, or ischemia of the affected limb². This may require a surgical exploration and repair of the injured structures.
• Compartment syndrome: The fracture or the cast may cause increased pressure within the muscle compartments of the limb, which may impair the blood flow and oxygen delivery to the tissues². This may cause severe pain, swelling, and tissue necrosis. This is a medical emergency that requires immediate fasciotomy (surgical release of the pressure).
• Malunion or nonunion: The fracture may heal in a wrong position (malunion) or not heal at all (nonunion), which may affect the function and appearance of the limb². This may require a surgical correction or revision of the fracture.

Closed reduction is an important technique used to treat displaced fractures. By reducing the fracture, the surgeon can minimize soft tissue trauma and improve patient comfort. To achieve a successful closed reduction, the following principles should be followed:

1. Respect the Soft Tissues

When performing a closed reduction, it is essential to respect the soft tissues surrounding the fracture site. Splints should be used that conform to the shape of the limb and avoid putting unnecessary pressure on the soft tissues. Bony prominences should be padded to prevent pressure sores, and allowance should be made for post-injury swelling.

2. Adequate Analgesia and Muscle Relaxation

Adequate analgesia and muscle relaxation are critical for the success of closed reduction. Pain and muscle tension can make the reduction more difficult and increase the risk of complications such as tissue damage or fractures.

3. Correct or Restore Length, Rotation, and Angulation

One of the primary goals of closed reduction is to restore the correct position of the broken bones. This involves correcting any changes in length, rotation, and angulation that may have occurred due to the injury.

4. Specific Reduction Maneuvers

Different types of fractures require specific reduction maneuvers to achieve the desired outcome. For example, a hip fracture may require abduction or internal rotation, while femoral shaft fractures may require traction or axial compression.

5. Immobilize Joint Above and Below the Injury

To maintain the reduction, the joint above and below the injury should be immobilized. This prevents any movement that could displace the fracture and allows the bone to heal in the correct position.

6. Three-Point Contact and Stabilization

Three-point contact and stabilization are essential for maintaining most closed reductions. This involves using splints or other types of immobilization to ensure that the affected limb is stabilized in three different places.

Conclusion

Closed reduction is a nonsurgical procedure to set a broken bone without cutting the skin open. It is indicated for mildly displaced fractures that do not involve significant soft tissue or neurovascular injury. It is performed by manipulating the bone fragments back into their normal alignment and immobilizing them with a cast, splint, or brace. It has several benefits over open reduction, such as being less invasive, less painful, faster to recover, and lower in cost. However, it also has some risks, such as inadequate or loss of reduction, neurovascular injury, compartment syndrome, malunion, or nonunion. Therefore, it is important to select the appropriate method of fracture management based on the individual case and follow-up with regular radiographic and clinical evaluation to ensure optimal healing and function.

References

¹: Closed reduction of a fractured bone - MedlinePlus ²: Closed reduction fracture: What to expect, recovery, and benefits ³: PRINCIPLES OF CLOSED REDUCTION : Fracture Reduction - an overview | ScienceDirect Topics : Open Reduction Internal Fixation (ORIF) - OrthoInfo - AAOS : Closed Reduction - StatPearls - NCBI Bookshelf : Colles Fracture Reduction - YouTube : Supracondylar Fracture Reduction - YouTube : Hip Fracture Reduction - YouTube