AO basic course

1. AOTrauma Principles Course
Paraic Murray, IE
Tom Rüedi, CH
Surgical reduction techniques—direct and
indirect

2. Goals
• Differences between direct and indirect reduction
• Advantages and disadvantages of each technique
• Indications for use of direct and indirect reduction
techniques

3. Goals of surgical reduction
• To restore the correct relationship of adjacent
joints―restoration of length, axis and rotation in diaphyseal
and metaphyseal fractures
• To restore normal anatomy of articular fractures, including
the
disimpaction of depressed articular fragments
• To preserve vascularity to the bone and the surrounding
soft tissues
• To preserve or disengage endangered structures (nerves,
vessels, tendons)
 requires experience and careful planning

4. What is reduction?
• Anatomical reduction—restoring the correct position of
the fragments
- Put the bits where they belong
- Intuitively correct
• Functional reduction—restoring the fragments into such
a position that normal function will occur following
fracture union

5. Diaphyseal fractures
• Restoration of length, axis, and rotation
• Correct position of the adjacent joints
• Individual fracture fragments need not be anatomically
reduced

6. Reduction of diaphyseal fractures—
restoration of normal joint relationship

7. Articular fractures
• Anatomical reduction where possible is essential for
cartilage healing and normal joint function
• Functional and anatomical reduction are the same thing

8. Definition of surgical reduction
• Direct reduction implies the exposure of the fracture
focus with direct manipulation of the different fragments
by instruments.
• Indirect reduction is performed without opening the
fracture zone, by applying traction forces away from that
area. This reduction technique is often combined with
minimally invasive surgical approaches.
• Biological reduction implies a respectful balance
between the two, and skillful
fragment handling in any kind of
operative fracture fixation to reduce
further damage to vascularity.

9. Direct reduction
• Fragments are manipulated directly and reduced
• The fracture is usually exposed—but not always
• 2-part diaphyseal fracture, direct reduction is easy
• Length, axis, and rotation restored

10. Reduction
forceps: standard and pointed (Weber) forceps
Advantages: Direct manipulation of fragments
Weber‘s: little periosteal damage, percutaneous
applications possible
Hazards: Slipping off the bone, squeezing of tissues,
repeated applications
Instruments for direct reduction

11. Direct manual reduction using two
pointed reduction forceps

12. Special reductions tools
Faraboeuf clamp
Advantages
Reduction in several planes incl.
compression
Hazards
Requires wide exposure, screw
pull-out

13. Hohmann retractor
• Advantages: Big force with little exposure as directly
applied to fracture gap
• Hazards: Additional fragmentation, loss of reduction
upon Hohmann removal

14. Direct fracture reduction
Indications: “Need to see”
- Articular fractures
- Simple metaphyseal fractures
- Irreduceable fractures
- Osteotomies, nonunions
- Anatomical reconstruction
- Absolute stability by rigid fixation
Hazards: - Too wide exposure
- Too much stripping of periosteum

15. Articular fractures must be reduced anatomically,
which requires good visualization of entire joint,
including critical structures like the ulnar nerve

16. Indirect reduction
• Forces and moments are applied at a remote distance
from the fracture site
• Indirectly reduce the fracture
• Respect the biology of the fracture: blood supply
• Assist reduction with:
- pointed reduction forceps
- dental probe

17. Traction
• Fracture table
• Femoral distractor
• External fixator
• External fixator across a joint
• Manual traction

18. Indirect reduction—use of external
fixator

19. Indirect reduction—use of femoral
distractor

20. Indirect reduction—use of push-pull
screw

21. Indirect reduction—use of a plate

22. Indications: intraarticular fractures with meta-/diaphyseal
extension
Distractor:
 for indirect alignment of length and axis
Pointed reduction forceps/K-wires, dental pick:
 for direct fine tuning
Combinations of direct and indirect
reduction techniques

23. What we have learned
• Some of the differences between direct and indirect
reduction
• Advantages and disadvantages
• Indications for direct and indirect reduction

24. Assessment of reduction
• Direct inspection direct reduction
• Palpation, instrument, joint surface
• X-ray, image intensification
• Arthroscope
• Axis, check with the diathermy cord

25. Conclusions
• Direct reduction has a firm place in fracture surgery with
clear indications
The goals are:
• to be as gentle and atraumatic as possible with minimal
exposures  biological reduction
• Fracture reduction must be planned step by step incl.
instrument position and reduction maneuvers
• Direct and indirect techniques may be combined