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Reduction is a medical procedure to restore the correct anatomical alignment of a
fracture Fracture is the appearance of a crack or complete separation of an object or material into two or more pieces under the action of stress (mechanics), stress. The fracture of a solid usually occurs due to the development of certain displacemen ...
or
dislocation In materials science, a dislocation or Taylor's dislocation is a linear crystallographic defect or irregularity within a crystal structure that contains an abrupt change in the arrangement of atoms. The movement of dislocations allow atoms to sli ...
. When an injury results in a
fracture Fracture is the appearance of a crack or complete separation of an object or material into two or more pieces under the action of stress (mechanics), stress. The fracture of a solid usually occurs due to the development of certain displacemen ...
, or broken bone, the bone segments can sometimes become misaligned. This is referred to as a displaced fracture which requires the medical procedure called reduction. Some providers may refer to this as 'setting the bone'. When an injury results in a
dislocation In materials science, a dislocation or Taylor's dislocation is a linear crystallographic defect or irregularity within a crystal structure that contains an abrupt change in the arrangement of atoms. The movement of dislocations allow atoms to sli ...
of a joint, or the misalignment of two connecting bones, a similar process of reduction must be performed to relocate the joint back into normal anatomical positioning. In the case of both displaced fractures and joint dislocation reduction is required for effective healing.


Fracture Reduction

There are two main categories of fracture reductions, closed reductions and open reductions. Both procedures require confirmatory imaging, such as
x-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...
, before the reduction to confirm the misalignment of bones and after the reduction procedure to confirm successful achievement of anatomical positioning.


Closed Reduction

Closed reduction is when bone alignment is achieved from external manipulation of the bone without having to open the skin. This is not a surgical procedure and is often performed in the emergency department with local anesthetic for pain management. A distal radial fracture (wrist) is a common injury that requires a closed reduction.


Open Reduction

Open reduction is a surgical procedure in which bone alignment is achieved from internal manipulation of the bone when the skin is open. After reduction of the fractured site it is common that fixed hardware is put in place to maintain anatomical alignment during bone healing, this process is called fixation. While many open reductions require either
internal Internal may refer to: *Internality as a concept in behavioural economics *Neijia, internal styles of Chinese martial arts *Neigong or "internal skills", a type of exercise in meditation associated with Daoism * ''Internal'' (album) by Safia, 2016 ...
(ORIF) or external fixation (OREF) there are some fractures that, after open reduction, do not require fixation.


Dislocation Reduction

Reductions for dislocations are dependent on the joint they involve. Common dislocations include the
shoulder The human shoulder is made up of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone) as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder m ...
, finger,
hip In vertebrate anatomy, the hip, or coxaLatin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) (: ''coxae'') in medical terminology, refers to either an anatomical region or a joint on t ...
,
knee In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia (tibiofemoral joint), and one between the femur and patella (patellofemoral joint). It is the largest joint in the hu ...
and
patella The patella (: patellae or patellas), also known as the kneecap, is a flat, rounded triangular bone which articulates with the femur (thigh bone) and covers and protects the anterior articular surface of the knee joint. The patella is found in m ...
. In children the elbow is also a common dislocation and referred to as nursemaid's elbow. There are many techniques but the same tenets are generally applied to all dislocation reductions. Traction, or sustained pulling pressure, is applied to the distal bone of the dislocated joint to relax the surrounding musculature and create space for the bone to move back into anatomical position. Traction can be applied either by human strength or with a system of pulleys and weights. Surrounding muscles, nerves and vasculature can be disrupted during the initial injury which can result in further surgical requirements even if proper bone alignment is achieved.


Procedural Medications

Open reductions are done under
general anesthesia General anaesthesia (UK) or general anesthesia (US) is medically induced loss of consciousness that renders a patient unarousable even by painful stimuli. It is achieved through medications, which can be injected or inhaled, often with an analgesi ...
administered by anesthesiologists in the operating room. Closed reductions are most often done with the aid of multimodal pain medications, sedatives and/or local anesthesia. Commonly a state of moderate sedation, or ''conscious sedation,'' is desired to reduce patient stress from the experience and relax the patient to improve in the manipulation during reduction.
Ketamine Ketamine is a cyclohexanone-derived general anesthetic and NMDA receptor antagonist with analgesic and hallucinogenic properties, used medically for anesthesia, depression, and pain management. Ketamine exists as its S- (esketamine) a ...
and
Midazolam Midazolam, sold under the brand name Versed among others, is a benzodiazepine medication used for anesthesia, premedication before surgical anesthesia, and procedural sedation, and to treat psychomotor agitation, severe agitation. It induces ...
are common choices for pediatric conscious sedations and are often given in conjunction with a short acting opiate like
fentanyl Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic (pain medication). It is 30 to 50 times more Potency (pharmacology), potent than heroin and 50 to 100 times more potent than morphine. Its primary Medici ...
. In adults
propofol Propofol is the active component of an intravenous anesthetic formulation used for induction and maintenance of general anesthesia. It is chemically termed 2,6-diisopropylphenol. The formulation was approved under the brand name Diprivan. Nu ...
,
midazolam Midazolam, sold under the brand name Versed among others, is a benzodiazepine medication used for anesthesia, premedication before surgical anesthesia, and procedural sedation, and to treat psychomotor agitation, severe agitation. It induces ...
and
etomidate Etomidate (United States Adopted Name, USAN, International Nonproprietary Name, INN, British Approved Name, BAN; marketed as Amidate) is a short-acting intravenous anaesthetic agent used for the induction of general anaesthesia and sedation for ...
are frequently used for conscious sedation with a short acting opiate like fentanyl. Local
hematoma block A hematoma block is an analgesic technique used to allow painless manipulation of fractures while avoiding the need for full anesthesia. When a bone is fractured as a result of an injury, the two fragments may be displaced relative to each other ...
s are also commonly employed for the reduction of forearm fractures. Hematoma blocks are when a local anesthetic like lidocaine is injected into the fracture site under the guidance of ultrasound to allow for fracture manipulation and reduction without pain or the need for systemic medications. NSAIDs and acetaminophen continue to be mainstays of pain management due to their efficacy and safety


Procedural Risks and Complications

Risks and complications from reductions include but are not limited to further damage to the fracture or dislocation, damage to surrounding structures and tissues such as nerves, muscles, and blood vessels. There is also a risk of an unsuccessful reduction which might require multiple attempts and prolonged need for medication administration or switching to a surgical intervention, in the case of dislocations and closed fractures. The medications administered during the procedure such as medications to block pain (
local Local may refer to: Geography and transportation * Local (train), a train serving local traffic demand * Local, Missouri, a community in the United States Arts, entertainment, and media * ''Local'' (comics), a limited series comic book by Bria ...
or
general anesthetic General anaesthetics (or anesthetics) are often defined as compounds that induce a loss of consciousness in humans or loss of righting reflex in animals. Clinical definitions are also extended to include an induced coma that causes lack of aware ...
) also have side effect profiles and risks of administration. Open reductions carry the risks of any
orthopedic surgery Orthopedic surgery or orthopedics ( alternative spelling orthopaedics) is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
, including but not limited to infection, hardware failures, damage to surrounding structures, and adverse reactions to general anesthesia. __TOC__


Recovery and rehabilitation

After a closed reduction, pain is expected for 2–3 weeks and potentially milder pain for up to 6 weeks.


References

* * (primary source) * {{DEFAULTSORT:Reduction (Orthopedic Surgery) Orthopedic surgical procedures