Page 394 - WSAVA2018
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 25-28 September, 2018 | Singapore
to 30 minutes, is possible to reduce the fracture by manipulation of the more movable fragment.
When performing manipulation always be alert to the possibility of laceration, perforation or compression of neurovascular structures.
In open reduction the fracture lines are exposed surgically, and the bone fragments are reduced under direct vision with instruments applied directly to each fragment, usually near the fracture side.
Open reduction is usually indicated for articular fractures, fractures that are unstable and complicated, fractures of several days of duration and those fractures that require internal fixation.
Reduction techniques must be gentle and atraumatic.
A good preoperative planning include a good knowledge of the anatomy and surgical approach to the area.
The surgeon should do any effort to respect any remaining vascularity and to avoid soft tissue stripping in order to preserve the biologic healing potential. Keep in mind that increased injury trauma requires decreased surgical trauma.
Strict haemostasis should be obtained by conscious use of electrocoagulation. A combination of frequent, copious irrigation with Ringer’s solution and gentle suction helps to maintain a clean area allowing a good visualization of the operative field. The fragments are handled carefully during exposure and reduction, in order to preserve any soft tissue attachment.
If anatomical reconstruction is possible, the fragments are fixed in place with lag screws, wires or Kirschner wires. Fragments that are to small for internal fixation should be left untouched to preserve their blood supply.
As a general rule, all fragments must be kept weather or not they have soft tissue attachments as they will function as an autogenous bone graft.
Instruments and Methods of Open Reduction.
Bone Holding Forceps:
The fracture can be reduced with application of direct force using bone holding forceps on one or more bone fragments. (FIG 1a -b)
FIG 3-a
In an oblique diaphyseal fracture, reduction is secured with the application of another pointed reduction forceps applied more or less perpendicular to the fracture plane. Fig 3 b
 FIG 1-a
FIG 1-b
An oblique fracture overriding can be reduced with a bone holding forceps grasping obliquely each main fragment. With some pressure and simultaneous rotation of the handles the bone is
lengthened and the fragments are reduced. (FIG 2a -b)
 FIG 2-a
FIG 2-b
The disadvantage of this technique is the tendency of the forceps to slip on the bone surface, adding further damage to the periosteal sleeve.
One other application consists of grasping each of the two main fragments of a transverse fracture with pointed reduction forceps, lengthening is achieved by manual distraction while proper axial alignment can be controlled with the forceps. (FIG 3a)

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