The most important adage to remember for the surgical management in traumatic orthopedic complaints is ‘Reduce – Hold – Rehabilitate’. In the context of high-energy injuries, this is precluded by resuscitation following ATLS (Advanced Trauma Life Support) principles (beyond the scope of this article). Reduction involves restoring the anatomical alignment of a fracture or dislocation of the deformed limb. Reduction allows for: Tamponade of bleeding at the fracture site, Reduction in the traction on the surrounding soft tissues, in turn reducing swelling, Excessively swollen soft tissues have higher rates of wound complications, and surgery may be delayed to allow this to regress, Reduction in the traction on the traversing nerves, in turn reducing the risk of neuropraxia, Reduction of pressures on traversing blood vessels, restoring any affected blood supply. The main principle in any reduction, regardless of the method employed, is to correct the deforming forces that resulted in the injury. Prior to this, some clinicians may suggest an initial exaggeration of the fracture, before the definitive reduction manoeuvre, aiding to uncouple the proximal and distal fracture fragments. Fracture reduction is typically performed closed in the emergency setting. However, some fractures are also reduced open (by directly visualising the fracture and reducing it with instruments) or intra-operatively. Reduction is painful and requires analgesia. Where regional or local blockade is both sufficient and easily provided (e.g. phalangeal/metacarpal/distal radius fractures), this would be the method of choice. More commonly, the patient requires a short period of conscious sedation, often provided by the A&E doctors in a setting that has access to anaesthetic agents, airway adjuncts, and monitoring (most Emergency Departments can provide this in a specialist anaesthetic room or in a resuscitation area). The specific manoeuvre used invariably requires two people (one to perform the reduction manoeuvre and one to provide counter-traction). A third person is typically needed to apply the plaster.
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