Distal Radius Reduction Technique

Distal Radius Reduction Technique

Distal Radius Reduction Technique

Important Concepts to Know

Discussion with the patient

  • Gather HPI, pertinent history, side of their dominant hand. 

  • Explain the plan 

    • “Hematoma block vs. sedation plan”

  • Future plan

    • “Common to need weekly xrays and evaluate for further displacement, if it displaces or is quite unstable surgery may be needed.”

  • Limitations 

    • “non weight bearing, but okay to move fingers to help decrease swelling”

Materials Needed

  • Mini C-arm fluoroscopy (very helpful)  

  • 10ml of 1% lidocaine (w/ Epi is okay)

  • 18g needle

  • Chlorhexidine or alcohol swabs

  • Gauze

  • Adult

    • 4” Webril (cotton)

    • 4” Rolled plaster splint

    • 4” Acewrap 

  • Child

    • 3-4” materials the same as for adults depending on size and age

    • No great age cut offs, some young kids are very large, some older children are small

Do you use a Hematoma Block or Sedation?

 

(A hematoma block is where you inject lidocaine into the fracture site.) 

 

  • Poor candidates for hematoma block

    • Stiff patients that can’t relax: Parkinsons, strokes (very stiff, can’t relax, this will make the reduction quite difficult

    • Highly anxious patients: Young men and women <30-40 years old

      • Some are fine, this is when you need to just talk to the patient and see how they are doing

      • If highly anxious I like using Versed (midazolam) with my hematoma blocks more than short acting opiates like fentanyl (often you can’t use both because it can be too sedating and fits the criteria for an official sedation if you use both) – this is likely hospital dependent

    • Subacute fractures (if the fracture is over 1 day old, poor lidocaine distribution due to clotting at fracture site)

    • Open fractures

  • When to use sedation?

    • Allergies to lidocaine (can’t hematoma block safely)

    • Stiff patients

    • Highly anxious patients

    • Open fractures

    • Multiple fractures on the same limb

    • Polytraumas

Steps

  • Always ensure there are updated xrays showing the injury. Even if they had xrays a few days ago. Get updated xrays prior to any reduction. 

  • Introduction and verbal consent (I just explain the plan)

  • Hematoma block (This gets the lidocaine working as soon as possible)

    • Good to get the lidocaine working first, it usually takes ~6-7 minutes to reach its peak effectiveness

  • Hematoma block steps

    • Forearm in pronation to view dorsal surface

    • Identify fracture site by palpation and site for injection

    • Injection site: 1- fingerbreadth proximal to fracture site centered on the radius (lined up with lister’s tubercle centered over distal radius or directed towards small fracture opening if not very displaced)

    • Mark and swab injection site with swab

    • Needle entry ~45 degree angle go right down to bone, walk distal towards fracture site, aspirate to look for flush of blood, this is how you know you are in the fracture

    • Inject and withdrawal plunger once to help mix and confirm location in hematoma (I haven’t found a benefit to redirect the needle if you already are getting a flush of blood)

    • Inject full 10ml amount

    • Let lidocaine work for 6-7 minutes for peak effect

  • Room setup (very important!)

    • C-arm coming up from feet

    • Patient lying down fracture side shoulder all the way to the edge of the bed

      • the elbow needs to be able to drop off the side of the bed

    • Set up strips of tape for securing acewrap

    • Set up sugartong splint

      • Ideal sugartong splint goes from distal palmer crease around elbow and ends just proximal to MCP joints the dorsal hand

      • Measure one layer of webril from volar PIP joint around elbow to dorsal PIP joint (longer than the final splint on purpose, plaster shrinks when wet)

        • Don’t stretch the webril when you measure! You will end up getting a splint that is too short

      • Lay our 4-5 stacked layers of webril with one separate layer off to the side (the one layer is used to cover the plaster after it has been dipped)

      • 10 layers of 4” plaster rolled out the same length as the webril template

      • Warm water in basin to dunk plaster

      • 2-3 4” Acewraps within reach of arm

    • You can set up finger traps, but we commonly use an assistant

    • Have them stand near the head of the patient, explain their job of holding down the arm for traction during reduction and then how to hold the thumb after reduction 

  • Technique:

    • Verify proper positioning and equipment

    • Coach patient to relax as much as possible or the reduction won’t work (the brachioradialis muscle attaches to the radial styloid, pulling on the fracture fragment causing it to displace/shorten

    • Coach the assistant 

      • Have them stand near the head of the patient, explain their job of holding down the arm for traction during reduction and then how to hold the thumb after reduction

      • Have them point their thumb towards the ground when holding the patient’s thumb after the fracture has been reduced

      • They must keep traction on the distal radius just pulling the patient’s thumb straight up and slightly volar to keep the radius reduced

      • The patient’s arm must be kept at 90 degrees

        • This keeps tension off the brachioradialis muscle and allows optimal position for the placement of the sugartong splint, so it doesn’t slide off the end of the elbow

    • Hold patient’s hand like a “bro-handshake”

  • Position your opposite hand’s thumb over the fracture fragment this is used to have more control over the fracture fragment during the reduction maneuver

  • The reduction maneuver will vary depending on the fracture type, but most distal radius fractures appear like this with a dorsally angulated and shortened distal radius, commonly with a ulnar styloid fracture fragment from a TFCC ligament avulsion:

 

 

  • Reduction maneuver (pictures 1-4 below):

  • 1. In a smooth motion, make the fracture more dorsally displaced (the term used is, “recreate” the fracture). Dorsal is more towards the posterior direction. 

  • 2 and 3. Keeping the distal radius fragment dorsally angulated, pull traction to get the posterior cortex out to length while pushing the fracture fragment with your opposite thumb to get the distal fragment out to length distally before hinging the fragment up on over, resting where it should be on the radius. 

  • 4. After the reduction always keep traction on the patient’s thumb and/or keep your opposite thumb on the fracture fragment to keep it in place or you will lose your reduction

  • Hand off the patient’s thumb to the holder. Have them keep traction on the patient’s thumb and have them place their opposite thumb on the fracture fragment to keep the piece reduced like in picture 4.

  • Go dip your plaster, between your fingers used in a “scissor formation” slide the plaster squeezing the water out and laminating the layers together

  • Place the plaster on the 4 layers of webril then lay the 1 layer of webril over top

  • Remember which side has the 4 layers of padded webril as this needs to go against the patient’s skin

  • Line up the slab of plaster with the distal palmar crease, padded side towards the skin, the thumb side corner can be folded to make extra room for the thumb

  • Fold any excess plaster backward to keep the MCPs (knuckles) visible to allow for ample finger motion when in the sugar tong splint

  • Wrap from the elbow up to the distal portion of the splint, leaving a thumb hole in the acewrap, don’t wrap too tight

  • When the plaster is placed, have the helper hold the same position, keeping a thumb on that fragment through the plaster

  • The helper should keep straight vertical and slightly volar traction on the patient’s thumb while you then perform your 3-point mold

    • For a Left distal radius fracture three point mold, you place your right palm on the distal fragment pushing volarly, your left palm just proximal to the fracture line, and then your right knee at the patient’s elbow/proximal forearm. You do the opposite for the patient’s other side. 

    • I usually like to check my reduction under fluoro after the splint has just started to set up. First I check the lateral, dropping the elbow, keeping it bent. If you do this you must keep the elbow bend at all times, keep the patient’s thumb in traction, and keep your thumb on the distal fragment keeping it reduced. You can raise the distal forearm ~15 degrees off the xray platform to shoot down the radiocapetallar joint to get a better sense of your reduction.

    • Hold the plaster until you can’t bend a corner of the splint, this is usually after the plaster material has started to cool down after its peak heat. If you let go too soon, you will lose your reduction

    • Always get post splint xrays. Ensure that your xray views are high quality so you can easily see if the fracture displaced when you see them in the next week in clinic. It is easy to get tricked into thinking that your reduction was inadequate with poor quality xrays where the rotation/position is off. Refer to the post on a system for reading wrist xrays for guidance. 

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