When outside forces are applied to bone it has the potential to fail.

Fractures occur when bone cannot withstand those outside forces. It is a complete or incomplete disruption in the continuity of bone structure. Clinical manifestations of fracture include acute pain, loss of function, deformity, shortening of the extremity, crepitus and localized edema and ecchymosis. Initial treatment for fractures of the arms, legs, hands and feet in the field include splinting the extremity in the position it is found, elevation and ice. Immobilization will be very helpful with initial pain control. Common medical management for fracture is Fracture Reduction. It refers to the restoration of the fracture fragments to anatomic alignment and positioning. Either closed reduction or open reduction may be used to reduce a fracture. The specific method selected depends on the nature of the fracture however; the underlying principles are the same. Usually, the physician reduces a fracture as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage. In most cases, fracture reduction becomes more difficult as the injury begins to heal. Some fractures require open reduction. Through a surgical approach, the fracture fragments are anatomically aligned. Internal fixation devices may be used to hold the bone fragments in position until solid bone healing occurs. In most instances, closed reduction is accomplished by bringing the bone fragments into anatomic alignment through manipulation and manual traction.

The goals of reduction are: To restore position (alignment, rotation and length) to the bone or joint, to decrease pain, to prevent later deformity, to encourage healing and normal use of the bone and limb. In the case of a fracture, it is also important for the bone ends to meet correctly (apposition).

Define related terms: Fracture - is a complete or incomplete disruption in the continuity of the bone structure and is defined according to the type and extent. Reduction- is a medical procedure to restore a fracture or dislocation to the correct alignment.

Open Reduction- refers to the method wherein the fracture fragments are exposed surgically by exposing the tissues. Closed Reduction- refers to the manipulation of the bone fragments without surgical exposure of the fragments.

Traction- is the application of a pulling force to a part of the body.

 Immobility- done after fracture has been reduced to maintain proper position and alignment until union occurs.

X-Ray- determine bone densities, texture, erosion, and changes in bone relationships. MRI (Magnetic Resonance Imaging) - obtains images of internal organs and tissues not readily visible on standard X-Rays.

Arthroscopy- allows direct visualization of a joint to diagnose joint disorders. Splint- device designed specifically to support and immobilize a body part in a desired position.

Cast- rigid external immobilizing device molded to contours of a body part. Sling- bandage used to support an arm.

Indication and Purposes of Closed Reduction:

Closed Reduction is used to reduce a fracture. No skin incision or cuts is required in the procedure. The doctor may suggest a closed reduction if your bone is broken in one place and has not broken the skin.

It is usually attempted first especially if the bones in a joint are intact but out of position or dislocated. With Closed Reduction, the bone will often slip back into its place. Sometimes pressure is also applied to guide the bones into correct position. Muscle spasm is often difficult to overcome without pain control (analgesia) or sedation.

PATIENT PREPARATION: Plan for care and recovery time after the operation is over, especially if you are to have general anesthesia. Allow for time to rest and try to find other people to help you with your day-to-day duties. Follow the instructions provided by the doctor. Do not eat or drink anything after midnight and the morning before the procedure. Do not even drink coffee, tea, or water after midnight. No particular preparation is needed for a sedative.

 PREPARATIONS for the Nurse: - Obtain consent from the patient that closed reduction will be done. - The nurse gives the patient information about the underlying pathologic condition and the purpose and expectations of the prescribed treatment regimen to promote patients active participation and compliance with treatment program.. - Check if X-Ray, MRI or arthroscopy has already been done because it identifies the fracture and identifies the diagnosis. Make sure that it is not an open fracture because with such, no attempt is made to reduce the fracture. - Patient must be evaluated completely before procedure for correct diagnosis. The nurse completes an assessment of the patients general health, presenting signs and symptoms, emotional status, understanding of the need of procedure and condition of the body part involved in the procedure. - Immobilize the body part affected before the patient is being moved because it controls pain associated with the underlying condition. - Splinting is essential to support body part in position. - Nurse monitors circulation, motion and sensation on the affected extremities comparing them with the opposite extremity for early recognition of diminished circulation and function. - Restrict patient from doing weight- bearing activities until the fracture has healed.

- Tell patient that a local anesthetic, opioid analgesic, muscle relaxant sedative or general anesthesia will be administered depending on the doctors order to overcome procedure without pain and assist the patient during closed reduction procedure. - The injured extremity must be handled gently to avoid additional damage.

PROCEDURE: CLOSED REDUCTION

Patient is being positioned and draped, then given a sedative or general anesthesia. A general anesthetic will relax the muscles and make the patient feel as if you are in a deep sleep. It will prevent you from feeling pain during the operation. The doctor pushes the broken bone into a position where it can heal properly. The extremity is held in the aligned position while the physician applies a cast, splint or other devices. Support is being given to the extremity or body part being casted or splinted. Reduction under anesthesia with percutaneous pinning may also be used. The immobilizing device maintains the reduction and stabilizes the extremity for bone healing. X- Rays are obtained to verify that the bone fragments are correctly aligned. Although rarely done, Closed Reduction may be accomplished by Traction (skin or skeletal) at or across the fracture to relax and lengthen the muscles and then manipulating the bone fragments back into normal position and holding this newly achieved position may be used until the patient is physiologically stable to undergo surgical fixation.

 POST- PROCEDURE CARE:

- Check Vital signs as frequently as clinical condition indicates. - Monitor neurovascular status for compression of nerve, diminished circulation, or development of compartment syndrome (palpable tightness of muscle compartment). - Tell patient to recognize and report symptoms needing attention, such as numbness, decreased function, increased pain or elevated temperature. The patient may go home later in the day depending on how the patient is doing and on the treatment. They may have a splint, dressing, or cast to help keep the bone in place while it heals. The patient can ask the doctor what steps should be taken and when to come back for a checkup.

SUPPORTIVE CARE:

- If patient applied with cast, teach cast care instructions. - Relieve pressure caused by immobilizing device as prescribed. - Relieve pressure on skin to prevent development of pressure ulcers; employ frequent positioning, skin care and special mattresses. - Prevent development of thromboembolism, Encourage active and passive ankle exercises. - Evaluate patient for proper body alignment and pressure from equipment that may cause pain.

- Encourage non- pharmacologic measures for pain reduction such as distraction and guided imagery. - Administer prescribed medications as indicated. - Assist with activities of daily living as needed. - Teach the family ways to assist the patient while promoting independence in self-care. - Perform active and passive exercises to all non-immobilized joints. - Encourage patient participation in frequent position changes, maintaining supports to fracture during position changes. - Minimize prolonged periods of physical inactivity, encouraging ambulation when prescribed. - Teach relaxation techniques to decrease anxiety.