Closed Reduction Maneuvers Research Articles

Biomechanical and clinical assessment of dissociation in bipolar hip hemiarthroplasty

Background Dissociation is a special type of dislocation that is rarely seen in bipolar hemiarthroplasty. Objectıve To investigate the clinical and biomechanical causes of dissociative dislocation of acetabular cup components in the hips of patients after bipolar hemiarthroplasty (BHA). Methods BHA heads were divided into three groups according to their design. Cam-out and pull-out biomechanical tests were conducted to investigate the separation strengths of the BHA heads. Results Among the 1684 BHA surgeries performed, the revision surgery rate was 4% (68 hips) and dissociation rate was 0.8% (15 hips). According to the cam-out test result, the highest values in the parameters ultimate force (Fmax) ultimate torque (T), vertical displacement at maximum force (δm), rotation at maximum force (ϕm), maximum principal strain (Ɛmax), minimum principal strain (Ɛmin), average normal strain (Ɛav), maximum shear strain (γmax), uniaxial normal strain (Ɛun) were detected in Type 2 BHA head. The pull-out values of the implants were sufficient to prevent the distraction force that may occur on the implant due to manual traction applied to the hip dislocations. However, in closed reduction maneuvers, cam-out-shaped deformation forces may cause dissociation in Types 1 and 3, but not in Type 2 BHA heads. According to the pull-out test results, while high values were detected in the parameters Fmax and stiffness ( k) in the Type 2 BHA head, δm and maximum force (E) parameters were found to be high in the Type 1 BHA head. In the cam-out test, a strong positive relationship was found between the thickness and width of the polyethylene locking ring and Fmax, T, δm, ϕm, Ɛmax, γmax, Ɛun. Conclusıon Better BHA head designs and polyethylene designs may help resolve the rare problem of dissociation, which almost always leads to resurgical procedures.

Management Options for Traumatic Posterior Sternoclavicular Joint Dislocation: A Narrative Review with a Single Institution's Experience.

Background: Posterior sternoclavicular joint (SCJ) dislocations are rare events that can evolve into real emergencies due to the vital structures in the mediastinum. When closed reduction maneuvers fail, open SCJ reconstruction becomes mandatory, with literature proposing several stabilization techniques that either preserve or remove the SCJ's mobility. This study is a narrative review of the most recent literature regarding posterior trauma to the SCJ along with a single institution's experience of this pathology, managed either conservatively or surgically, with a figure-of-eight autologous semitendinosus graft in case of closed reduction failure. Methods: This article provides an overview of posterior traumatic SCJ dislocation, and it describes five cases of patients managed for traumatic posterior SCJ dislocation treated either conservatively or surgically with a figure-of-eight semitendinosus tendon autograft reinforced with high-strength suture tape. A comparison with the most recent literature is performed, focusing on biomechanics. Results: The demographics, the mechanism of injury, the management algorithm and the surgical strategy align with the most recent literature. Despite the final treatment, at one year of follow-up, the ROM was restored with full strength throughout the range of motion of the shoulder with no neurological deficits. The reduced joint successfully healed in imaging, and patients returned to their daily lives. The surgical site wounds and donor harvest sites were perfectly healed. Conclusions: Although recent recommendations for treating posterior traumatic SCJ dislocation have advanced, no universally accepted method of stabilization exists, and the surgical strategy is generally entrusted to the surgeon's experience. The literature still increasingly supports figure-of-eight ligament reconstruction with a biological or synthetic graft. This work further implements the literature by reporting good outcomes at follow-up.

Use of paralytic agents during the operative treatment of type III supracondylar humerus fractures in children: A single-center investigation and survey of Pediatric Orthopaedic Society of North America members

Use of paralytic agents during the operative treatment of type III supracondylar humerus fractures in children: A single-center investigation and survey of Pediatric Orthopaedic Society of North America members

A novel technique for successful closed reduction of a lisfranc fracture-dislocation

The purpose of this study is to present a novel technique for the closed reduction of a divergent Lisfranc fracture-dislocation. Successful closed reduction of this injury limits the morbidity associated with soft tissue compromise that may otherwise delay definitive surgical fixation. A combination of weighted axial traction/counter-traction with a two-stage manipulation of the medial/middle and middle/lateral columns of the mid- and forefoot was performed. A Kling was affixed to the hallux and second ray within closed loops, then mounted to an intravenous pole. Weight was then applied to the distal tibia. Axial traction-counter traction and manual plantar translation with medial to lateral compression were then combined until successful reduction of the first and second metatarsal was achieved. The third, fourth and fifth metatarsals were hyper-dorsiflexed and abducted with subsequent inline manual traction and lateral to medial compression over the base of the metatarsals. This was followed by plantarflexion and adduction to complete the reduction maneuver. : A combination of weighted axial traction/counter-traction with two-stage manipulation of the medial/middle and middle/lateral columns of the mid- and forefoot was performed to successfully reduce a divergent Lisfranc fracture-dislocation. Successful closed reduction avoided the need for acute open reduction and mitigated the risk of soft tissue compromise, neurovascular complication, and compartment syndrome. This novel technique for reduction permitted percutaneous internal fixation due to the satisfactory alignment obtained from the closed reduction maneuver. Early closed reduction obviates the need for acute open reduction and limits soft tissue morbidity. This permits orthopaedic surgeons to non-urgently manage Lisfranc fracture-dislocations with definitive surgical fixation that is amenable to either percutaneous techniques or open reduction and internal fixation.

Metacarpal Fractures

Hand-related trauma is a common injury accounting for nearly a million emergency department visits annually. Fractures involving the metacarpals comprise approximately 40% of all hand injuries. Sports-related injuries are seen most often in children and young adults; middle-aged workers suffer more motor vehicle accident or work-related/industrial injuries; and the elderly seems to injure their hands from ground-level falls. The most commonly reported hand fracture involves the fifth metacarpal neck. Metacarpal fractures are described by their bone location in which they occur (head-neck-shaft-base). Fracture patterns are referred to as transverse, oblique (short/long), or comminuted based on fracture line configuration. The predominance of metacarpal fractures is closed injuries. However, open metacarpal fractures can result from severe bone and soft-tissue trauma caused by bone fragment(s) lacerating the skin. Small finger metacarpal neck fractures have the highest probability of being associated with an open fracture because of their injury mechanism. The primary goals of metacarpal fracture treatment are to achieve acceptable alignment, stable reductions, bony union, and full motion. Bone fracture location, fragment(s) size, and fracture pattern will influence treatment decisions. Most metacarpal fractures can be treated nonoperatively with closed reduction maneuvers and splinting. Metacarpal fractures associated with open injuries can be treated effectively with early detection, copious irrigation, antibiotic therapy, appropriate wound coverage, and fracture immobilization. Surgical considerations of metacarpal fractures include malunion, failure to maintain fracture reduction, polytrauma, and open fractures resulting in severe soft-tissue trauma.

Changes in the anatomical position of the superficial and deep femoral arteries during internal fixation of intertrochanteric fractures

Fixation for intertrochanteric proximal femoral fractures are increasing globally, one of the risks with surgical treatment is injury to the deep and superficial femoral arteries (DFA and SFA, respectively). The anatomic path of these vessels has been previously described, though the effect of reduction techniques, such as traction over a perineal post has not been well defined. This study addresses the question of: do closed reduction maneuvers on an orthopaedic trauma traction table affect the anatomical relationship of superficial and deep femoral arteries to the proximal femur in intertrochanteric proximal femoral fractures? Prospective observational single centre study of seventeen patients with pertrochanteric femoral fractures examined before and after applying traction for closed reduction. Doppler ultrasound was used to determine the proximity of these arteries to the proximal medial femoral cortex at three different levels. Our data demonstrates that internal rotation of the injured limb during reduction draws the arteries statistically closer to the medial cortex of the proximal femoral shaft at 3.5cm and 10.5cm distal to the lesser trochanter (SFA: 3.5cm - 38.0mm vs 34.7mm p 0.004, 10.5cm – 30.4mm vs 21.0mm p 0.02; DFA: 3.5cm – 26.4mm vs 22.3mm p 0.003, 10.5cm - 21.5mm vs 14.1mm p 0.007). No significant change in the artery position was noted in patients who did not require internal rotation to achieve fracture reduction. Surgeons performing these internal fixation procedures need to be aware of the anatomical changes to ensure patient safety and avoid complications including intramuscular haematomas and pseudoaneurysms. • Internal rotation laterally displaces the femoral artery during fixation on an orthopaedic traction table. • Care should be taken to avoid drill plunge beyond the medial femoral cortex. • Deep femoral artery is most ‘at risk’ of injury when using plate or distal locked nail constructs.

Neglected Simultaneous Bilateral Asymmetric Traumatic Hip Dislocation in a Young Male Managed by Closed Reduction Manoeuvres in a Resource-Limited Setting: A Case Report

Neglected Simultaneous Bilateral Asymmetric Traumatic Hip Dislocation in a Young Male Managed by Closed Reduction Manoeuvres in a Resource-Limited Setting: A Case Report

Dislocation after reverse total shoulder arthroplasty using contemporary medialized modular systems. Can we still consider it such a frequent complication?

Improvement in reverse total shoulder arthroplasty (RTSA) prosthesis and technique has reduced the initially high complication and revision rates associated with this implant. However, instability continues to be a leading cause of reoperation after RTSA, being related in previous studies with medialized designs. The aim of this study was to determine the dislocation rate with the employment of two medialized modular systems of RTSA in our institution. A retrospective review of two different modular systems of RTSA (SMR Modular Shoulder System and Delta XTEND Reverse Shoulder) was performed between 2009 and 2017 with a minimum 3-year follow-up. Baseline demographic, clinical (Constant, ASES and ROM), and radiographic data were collected. Characteristics of postoperative instability cases were also evaluated. 237 primary RTSA (41% SMR/59% Delta) and 34 revision RTSA (44% SMR/56% Delta) with a mean follow-up of 75.6 ± 5.2months (79.2 SMR/86.3 Delta, p = .586) were included in the present study. Indications for primary RTSA were osteoarthritis, rotator cuff tear arthropathy and massive irreparable rotator cuff tear (64%), acute fracture (32%), and fracture sequelae (4%). Subscapularis tendon was always repaired in degenerative pathology and tuberosities reattached in traumatic cases. The mean age of the global series was 76.5 ± 5.3years (75.8 SMR/78.6 Delta, p = .104) with a mean Constant/ASES score at final follow-up of 68.5 ± 4.3/72.9 ± 20.3 (71/68 SMR and 69/74 Delta, p = .653 and .642). Only 2 patients (one acute fracture and one fracture sequelae) suffered an early postoperative anterior dislocation (before 3months) which represents a rate of .84% in primary cases and .73% including revision surgery. Closed reduction manoeuvres were not successful, and both patients required revision surgery. At the end follow-up, both were stable and had no further dislocations. The dislocation rate after RTSA with the employment of two contemporary modular systems with a medialized centre of rotation is extremely low, especially when compared with the previously published series with the original Grammont design. Acute fracture and fracture sequelae were the main diagnoses associated with this instability. The reasons for the low dislocation rate are multifactorial, but the improvement in the baseplate position according to the more recent standards of "ideal position" and technical aspects such as subscapularis repair or tuberosity reattachment in fractures probably play an important role in this aspect.

Closed Pantalar Dislocations: Characteristics, Treatment Approaches, and Outcomes.

Closed pantalar dislocation mainly occurs among male adults aged 20 to 45 years and is usually associated with high-energy trauma, mostly falls (50.0%). The talus dislocates anterolaterally in about 85% of cases. Pure pantalar dislocation is more common (54.7%) than cases with concomitant fractures (45.3%). Ankle fractures are the most common associated fractures, followed by fractures of the talar posterior process. Among 40 reported cases, 24 had successful closed reduction (60%), 11 had unsuccessful closed reduction (27.5%), and 5 underwent open reduction without attempting closed reduction (12.5%). The success rate for closed reduction of closed pantalar dislocation is 68.5% (24/35 cases). Post-traumatic arthrosis occurs in 32.3%. Osteonecrosis occurs less often than previously reported. Infection after closed reduction of pantalar dislocation is very rare except after open reduction and fixation for concomitant talar fractures. Conclusively, closed pantalar dislocations are very rare injuries and may portend a poor prognosis. Urgent talar relocation restores ankle and hindfoot anatomy and reduces pressure on surrounding soft tissues to optimize outcome. A closed reduction maneuver should be attempted initially, followed by urgent open reduction when the talus is not accurately reduced through closed means.

Adult Traumatic Inferior Hip Dislocation after Falling from a Height: A Report of Case

Inferior dislocation of hip joint is a rare clinical entity. Closed reduction maneuver could be challenging, especially if the attending surgeon is not familiar with specific anatomy associated with this injury. Herein, we reported a 22-years-old man brought to the Emergency department with history of accidentally falling from a height of 13 meters. He was managed with multidisciplinary approaches as a multiple trauma. He was complaining of severe hip pain. His right hip joint was flexed, externally rotated, and abducted. His pelvis was stable and the lower extremities had normal symmetric pulses. On radiologic examination, there was no associated hip fracture. He was brought to operating room for closed reduction under general anesthesia. Although traumatic hip dislocations usually have high morbidity and mortality rates due to multiple organ damages, patient was discharged 6 days after admission and advised to keep toe touch weight bearing for the next six weeks during walking. Therefore, a detailed evaluation on emergency presentation, a multi-disciplinary approach, and early diagnosis of inferior hip dislocation could be life-saving for such patients.

Haematoma block: a safe method for pre-surgical reduction of distal radius fractures

BackgroundThe haematoma block (HB) has been successfully used to minimise pain prior to otherwise painful closed reduction manoeuvres for distal radius fractures. However, the invasive manner of the procedure, which technically produces an open fracture, still raises the question, whether HBs increase the risk of infection compared to conventional intravenous analgesia (IA). The purpose of this study was to assess complication rates and safety of the HB procedure for the closed reduction of surgically treated distal radius fractures.MethodsWe included 176 distal radius fractures in 170 patients in a retrospective mono-centric study, who underwent closed reduction and casting followed by definitive surgical care over a period of two years. Patients either received a HB or IA before closed reduction and were evaluated for minor and major complications over a follow-up period of four years.ResultsOverall, 42 distal radius fractures were treated with a HB (23.9%) and 134 with IA (76.1%) before closed reduction. There were a single major (2.3%) and eight minor (19%) complications observed in the HB group compared to two major (1.4%) and 24 minor (17.9%) complications in the IA group. No significant differences were identified between the two groups. Sex and type of fracture had no effect on complication rates, however, younger patients experienced higher complication rates in comparison to older ones (p = 0.035).ConclusionAccording to our data, the apprehensions that clinicians may have of creating open fractures through HB procedures, are unnecessary and may be abandoned confidently.

Une nouvelle technique de réduction à foyer fermé utilisant une table de traction pour la réduction des luxations postérieures traumatiques de la hanche

Abstract Traumatic hip dislocations should be reduced gently and promptly to prevent complications such as osteonecrosis of the femoral head, heterotopic ossification, incomplete recovery of sciatic nerve injury, and fractures of the femoral neck. Many closed reduction manoeuvres have been reported; however, these manoeuvres require forceful and sustained traction, which places an enormous physical burden on surgeons. The aim of the present technical note is to describe a new reduction manoeuvre that uses a traction table to decrease the physical burden experienced by surgeons.

A new closed reduction technique using a traction table to treat a traumatic posterior dislocation of the hip joint

Traumatic hip dislocations should be reduced gently and promptly to prevent complications such as osteonecrosis of the femoral head, heterotopic ossification, incomplete recovery of sciatic nerve injury, and fractures of the femoral neck. Many closed reduction manoeuvres have been reported; however, these manoeuvres require forceful and sustained traction, which places an enormous physical burden on surgeons. The aim of the present technical note is to describe a new reduction manoeuvre that uses a traction table to decrease the physical burden experienced by surgeons.

Acute traumatic unilateral cervical C4\u2013C5 facet dislocation in pediatric toddlers

BackgroundThe present study is to highlight the challenges in managing cervical spine injuries in toddlers (less than 4 years of age) without neurological deficit. Cases of unilateral cervical C4–C5 facet dislocation in toddlers are very rare.Case presentationA 3-year-old girl suffered cervical spine injury after a motor vehicle collision with unilateral C4–C5 facet dislocation without neurological deficit. Magnetic resonance imaging (MRI) showed no spinal cord injury, Frankel grade E. Initial management was cervical spine protection. Definite treatment and complication were discussed with the patient’s parents before closed reduction maneuver with minerva cast was applied under sedation. The patient showed no complication after closed reduction and the cervical spine had aligned well in radiographs. The minerva cast was removed at 8 weeks, at which point neck muscle stretching rehabilitation program started. At one-year follow up, the child was asymptomatic, had full active cervical motion and good function. In radiographs, the cervical spine had normal alignment and was healed.ConclusionsUnilateral cervical facet dislocation in toddlers is very rare. Closed reduction maneuver and the minerva cast applied were optional in this case. The parents were highly satisfied with the effective treatment and outcome.

Pediatric Emergency Room Transfers: Are They Warranted?

Emergency room transfers to a higher level of care are a vital component of modern health care, as optimal care of patients requires providing access to specialized personnel and facilities. However, literature has shown that orthopaedic transfers to a higher level of care facility are frequently unnecessary. The purpose of this study was to assess the appropriateness of pediatric orthopaedic transfers to a tertiary care center and the factors surrounding these transfers. All pediatric orthopaedic transfers to the pediatric emergency department (ED) were evaluated over a 4-year period. A retrospective chart review was performed to assess the factors surrounding the transfer including patient demographics, time of transfer, day of transfer, insurance status, outcome of transfer, and diagnosis. Three independent variables were utilized to assess the appropriateness of the transfer: the need for an operative procedure, the need for conscious sedation, and the need for a closed reduction in the ED. A total of 218 pediatric orthopaedic emergency room transfers were evaluated, of which 86% of them involved an acute fracture. Twenty-seven percent (59/218) of the transfers occurred on the weekend, with over half (61%) of these transfers being initiated between 6 PM and 6 AM. Approximately half (47%) of the transfers involved patients with Medicaid. Fifty-five percent (120/218) of cases required a procedure in the operating room and 22% (49/218) had a closed reduction performed in the ED. Conscious sedation was provided in the ED for 22% (48/218) of patients. Twenty-two percent (47/218) of transfers did not require a trip to the operating room, conscious sedation, nor a closed reduction procedure in the ED. The vast majority of pediatric orthopaedic transfers are warranted as they required operative intervention, a closed reduction maneuver, or conscious sedation in the ED. Level III-Therapeutic.

The role of pre-reduction MRI in the management of complex cervical spine fracture-dislocations: an ongoing controversy?

BackgroundCervical spine fracture-dislocations in neurologically intact patients represent a surgical challenge due to the risk of inflicting iatrogenic spinal cord compression by closed reduction maneuvers. The use of MRI for early advanced imaging in these injuries remains controversially debated.Case presentationA 54-year old man sustained a fall over the handlebars of his racing bicycle. The helmeted patient sustained a fall on his head which resulted in a hyperflexion injury of the neck. He was neurologically intact on presentation. Initial CT imaging revealed a complex multisegmental cervical spine injury with a left-sided C6/C7 perched facet, a right sided C7/T1 fracture-dislocation, and a right-sided C6 and C7 traumatic laminotomy. The initial management consisted of temporary external Halo fixator application without closed reduction maneuver, to mitigate the risk of a delayed spinal cord injury. Subsequent advanced imaging by MRI revealed an acute traumatic C7/T1 disc herniation, with the intervertebral disc completely extruded into the spinal canal. Definitive surgical management was then accomplished by employing a three-stage anterior-posterior-anterior spinal decompression, realignment, fixation and fusion C4-T2 in one operative session. The patient recovered well and retained full neurological function. He resumed bicycle street racing within 10 months of the injury following successful spinal reconstruction.ConclusionsThe diagnostic evaluation of cervical fracture-dislocations should include advanced imaging by MRI in order to fully understand the injury pattern prior to proceeding with spinal reduction maneuvers which may impose the imminent threat of a devastating iatrogenic injury to the spinal cord. The presented staged management by initial Halo fixation without attempts for spinal reduction, followed by a surgical decompression and multilevel fusion, appears to represent a feasible and safe strategy for patients at risk of a delayed neurological injury.

Subtrochanteric fractures in elderly people treated with intramedullary fixation: quality of life and complications following open reduction and cerclage wiring versus closed reduction.

Subtrochanteric fractures are more difficult to treat than other proximal femoral fractures. The aim of this study was to report the outcomes for patients with subtrochanteric fractures treated using a cephalomedullary nail following open reduction and cerclage wiring versus closed reduction alone, regarding health-related quality of life (HRQoL) and social function. We performed a prospective cohort study including patients aged 60years or older suffering fragility subtrochanteric fractures of the femur treated with cephalomedullary nails, with a minimum 2-year follow-up. We defined two treatment groups: one treated with closed reduction manoeuvres (60 patients), and another treated with open reduction and cerclage wiring (30 patients). The outcomes were mortality, orthopaedic complications (reoperation and no-union), social function (Jensen Index), and HRQoL (EQ-5D index score). There were no differences regarding sex, age, side affected, type of implant, anaesthetic risk, 1-year mortality, and orthopaedic complications. Surgical time was longer in the cerclage wire group, but length of stay was 2days shorter for the cerclage group and reduction was better. Patients treated with cerclage wiring had significantly better EQ-ED at 12months (0.66±0.22 points vs. 0.78±0.15 points); and social status at 12 and 18months (2.77±1.00 points vs. 2.10±1.22 points). Better reduction is achieved when using cerclage wires for fragility subtrochanteric fractures. These fractures had a negative effect on quality of life and social function, but better outcomes were observed in the cerclage group.

The art of trochanteric fracture reduction

The name of Ender is primarily associated with the Ender nails, which were popular for trochanteric fracture fixation more than thirty years ago. However, Ender's concepts were not limited to the implant. Ender developed a unique classification system for trochanteric and subtrochanteric fractures, which provided the theory for closed reduction maneuvers that made the method so successful in his hands. While Ender's nails have become history in the meantime, his principles of fracture reduction can be readily applied on surgery with modern implants such as proximal femoral nails. This article reflects the classification and the principles published by Hans Georg Ender in some print work hardly available nowadays.

Two Adjacent Levels Dislocation of the Cervical Spine Managed via an Anterior Only Approach : A Case Report

We report the rare case of a 52-year-old man who presented an incomplete tetraplegia after a hang gliding accident. Computed tomography revealed a complete bilateral facet fracture-dislocation at the C4C5 level, with a unilateral facet fracture-dislocation on the left side at the C3C4 level; there was also a sagittal fracture of the fifth cervical vertebra extending through the middle of its body with a second fracture through the posterior arch. The patient was taken urgently to the operating room and closed reduction maneuvers were performed under general anesthesia, followed by an anterior prevascular approach for C3 to C5 fusion with two iliac crest grafts and a plate. Patient’s muscle strength was 3/5 on all four limbs on discharge and between 4/5 and 5/5 at one year. He stopped self-catheterization nine months after the accident. At two years follow-up, X-rays and CT scan showed a stable construct with satisfactory fusion. This is the first paper, in the literature, to describe double level contiguous cervical dislocation with a sagittal split fracture, and managed via an anterior only approach.

Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes of irreducibility

To define the unique radiographic features, operative treatment, and complications of pertrochanteric fractures (AO/OTA 31-A1 and A2) which are not amenable to the usual closed reduction manoeuvres. During a 2-year period (from August 2011 until December 2013), 212 patients with pertrochanteric fractures were treated at our level I trauma centre. A retrospective review was undertaken to determine which of these fractures were not reducible via the routine closed reduction manoeuvres and required some form of open reduction. These fractures were assessed for radiographic markers of irreducibility, surgical findings, reduction techniques, and perioperative complications. Twenty-four patients had fractures, which were not amenable to closed reduction and underwent open reduction. These fractures could be grouped into four patterns. A preoperative CT scan was available for at least two cases of each pattern, which provided further insights into the cause of irreducibility by closed means. These included a variant where the proximal fragment is locked underneath the shaft fragment (3 cases), bisected lesser trochanter with a locked proximal fragment (3 cases), irreducibility due to entrapped posteromedial fragment at the fracture site (6 cases) and a variant where the proximal fragment is flexed passively by the underlying lesser trochanter (12 cases). Pertrochanteric fractures, which are not amenable to closed reduction, are uncommon, but are heralded by unique radiographic features. These patients warrant special consideration in terms of recognition and management. The specific radiographic markers should alert the surgeon to this injury pattern and its related difficulty encountered during closed reduction. Once reduction is achieved, however, these fractures follow an uneventful course.