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WSV18-0320
ORTHOPEDIC SURGERY
TOP TIPS IN HOW TO REDUCE AND ALIGN FRACTURES: MINIMAL EFFORT FOR MAXIMUM OUTCOME
A. Piras1
1Specialist in Veterinary Surgery, Ravenna, Italy
Top Tips How to Reduce and Align Fractures: Minimal Effort for Maximum Outcome
Alessandro Piras
DVM - Specialist in Veterinary Surgery
Reduction is the process of either reconstructing the fractured bone to its normal anatomy by restoring the correct position of the fragments or restoring the normal alignment of the limb.
Conceptually reduction of a fracture reverses the process which created the fracture displacement during the injury and needs the application of forces and moments opposite to those that produced the fracture.
Consequently an accurate analysis of the level of displacement and degree of deformation represents a fundamental help in planning the strategies needed to achieve reduction.
This concepts apply despite of the reduction method applied, be this open or closed, manual or by skeletal traction, with or without instruments.
When a bone is fractured, the continuous tension generated by the muscles contraction, provoke shortening and overriding of the bone ends. The initial muscle spasm is aggravated by the concomitant injury of the soft tissues of the affected area. Post fracture oedema and haematoma will form in within few hours post injury and will fill the interstitial spaces and create fluid filled voids along tissue planes around the fractured area. The oedema generate hydrostatic forces that create additional shortening of the fractured extremity and an additional impediment to fracture reduction. After several days the inflammatory reaction in the
area accompanied by proliferating changes, leads to contraction of more permanent nature making the reduction attempts even more difficult.
OBJECTIVES OF FRACTURE REDUCTION
In diaphyseal and metaphyseal fractures the aim is to restore as precisely as possible the length, the axial and rotational alignments of the bone. Axial bending in the saggital plane is usually well tolerated unless is generating excessive limb shortening. A moderate degree of varus angulation of the distal segment, is generally better tolerated than valgus angulation that usually leads to significant functional problems.
Articular fractures demand anatomical reduction and absolute stability to enhance the healing of the articular cartilage and make early motion possible.
Residual displacement should not be tolerated in
order to avoid the development of post traumatic osteoarthrosis. Unfortunately this is not always possible and a better reduction can not be achieved without additional soft tissue damage, an extended or combined surgical approach, with consequently increased surgical time, all this increasing the risk factors and morbidity.
In this cases we have to consider that “better is enemy of good” and a less perfect reduction can be acceptable for the sake of respecting the local biology.
The secret of reduction is the application of continual steady traction over time. This will fatigue the muscles allowing reduction.
Methods of fracture reduction include open or direct reduction and closed or indirect reduction.
CLOSED REDUCTION
Reduction is obtained by application of traction, countertraction and manipulation of the limb. The fracture is not directly exposed and the fracture area remains covered by the surrounding tissues.
This method is ideal provided that it can be accomplished with minimal tissue trauma.
Traction can be applied either manually or by gravity.
To apply manual traction, the patient, under general anaesthesia, is positioned on a table on lateral recumbence on the side opposite to the fractured limb. A soft rope loop or a padded belt is placed around the axillary or groin region and is secured to the edge of the table near the patient’s back. A second rope loop is placed in the carpal or tarsal area and slow, continuous traction is applied. Manual traction is quite demanding and is difficult for the surgeon to be able to apply a slow and progressively increasing traction over the 10 to 30 minutes that are usually necessary to fatigue the muscle. The Gordon’s extender is a mechanical device that allows traction to be exerted without the surgeon exerting as much force.
The animal weight can be used to advantage when using gravity to obtain traction. The patient is placed on dorsal recumbence and a piece of tape, gauze or soft rope is placed around the metacarpal or metatarsal area of the affected limb. The attaching material is connected to an infusion stand or to a secure bolt in the ceiling and is pulled enough to raise the animal slightly off the table
so that part of the body weight is producing traction on the suspended limb. Traction can also be modulate by temporary lowering of the table.
When adequate traction is obtained, usually after 10
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