Fracture reduction is the method by which the fractured bones are reduced to the best possible anatomical alignment for the given situation. When a fracture reduction has achieved its objective the fracture is said to be reduced.
Fracture fixation is the term used when the fractured fragments are held in a reduced position. Depending on different types of gadgets and approaches used, there are different types of fracture fixation.
Reduction and fixation go together. First, the fracture is reduced [or fracture reduction is done] and then it is fixed by some implant.
Fixation methods are surgical procedures but the reduction is not always.
For example, in closed reduction and immobilization of a fracture, there is a fracture reductio that has been done but the reduced fragments are held in place by plaster application in a particular position of the limb.
There is no fixation in the above example though in effect plaster cast in essence attempts to fix the fragments in the position. The term fracture fixation is chosen only when the fracture is surgically fixed by using some implant.
Fracture fixation is also termed osteosynthesis.
We will discuss further different types of fracture reduction and fracture fixation combination and then find how these further give rise to well-conveying terms that at first may appear similar but are distinct.
The treatment has evolved from its earlier days and now includes many modalities. This article describes the basic terms of reduction and fixation.
Different Types of Fracture Reduction
Closed Reduction
The term open and closed in relation to fracture are based on whether the fracture hematoma is breached. Thus all those procedures [reduction maneuvers or surgical approaches] that do not breach the hematoma will come under the category of closed reduction].
For example, a fracture of the radius is reduced by traction and a plaster cast is applied. This procedure is closed reduction and plaster cast immobilization. Some authors also use the term cast fixation.
However, if desired, an intramedullary nail or k-wires can be pushed into the radius bone under C-arm image to hold the fracture fragments. But the reduction will still be called closed as fracture fragments were not exposed and instead were reduced in a closed manner.
This procedure will be called as closed reduction and internal fixation.
Most of the closed fracture surgeries involve internal fixation but less commonly external fixation [see later] may be used.
Open Reduction
This means the fracture fragments are surgically opened, accessed and reduced. This opens the fracture hematoma and therefore term open is used for this kind of reduction.
Before the advent of the C-arm, most of the surgical reductions were open reductions. Open reduction allows surgeons to visualize the fracture and reduce the fracture anatomically as the fracture is reduced under direct vision.
The reduced fracture is temporarily held with instruments and then surgically fixed with an implant of the desired nature.
Bone plating is typically an open reduction as in this surgery, fractured fragments are exposed and reduced and then followed by fixation with plate and screw.
Some modern anatomical plates allow closed reduction and fixation but the classically open reduction was carried.
[Read more about closed and open fractures]
Types of Fracture Fixation
After a fracture has been reduced, the fragments need to be held in place so that fracture healing may occur in an acceptable position.
Plaster immobilization is one of the methods to hold the fragments.
But implants are needed when we are doing surgery to fix the fragments so that they stay in reduced position and fracture healing occurs.
The aim of fixation is just that – to hold the fracture in a reduced position till it unites.
Depending on the implant type used, the fixation can internal or external
Internal Fixation
It is a type of fracture fixation where the fragments are fixed by a gadget that is buried beneath the soft tissues and is not visible externally. Plating is a type of internal fixation.
The implants used in this fixation are not visible or protruding outside the skin.
Most of the plates and screws and intramedullary nails are types of internal fixation.
Internal fixation is more preferred than external fixation in fracture fixation. This is because of the following advantages it offers
- No contact with the external environment, lesser chance of contamination
- External fixators require regular care
- The limb appears normal, there is nothing protruding from or encircling the limb
- Does not tether soft tissues
- Allow better mobilization when needed
External Fixation
In this kind of fixation, the fixing gadget is outside the soft tissue envelope and is visible to the naked eye. A tubular external fixator or Ilizarov external fixator is a type of external fixator.
Following is an example of an external fixator.
Ilizarov External Fixation Device
Image Credit: Wikipedia
Different Combinations of Fracture Reduction and Fixation
Open Fracture Reduction and Internal Fixation
This term is used when reduction of the fracture is done by surgically exposing the fracture and then fixing the fracture with the required gadget. A compression plating is a typical example of open reduction and internal fixation.
Closed Fracture Reduction and Internal Fixation
This term is often confusing. It becomes difficult to fathom how the reduction could be closed if the fracture has been fixed by surgery.
This term is easier to understand if we understand the fact that the terms open or closed fracture reduction is in relation to the exposure of the fracture site.
So if a fracture can be reduced by manipulation and a gadget can be introduced and fixed without exposing the fracture site, it would be called closed reduction and internal fixation.
Closed reduction because the fracture site was not opened to reduce the fracture and internal fixation because the gadget is buried under the soft tissue coverage.
This has been made possible by use of image intensifier which allows a view of structures during surgery.
A closed interlock nail is an example of closed reduction and internal fixation.
Closed Fracture Reduction and External Fixation
Sometimes, the fracture is not disturbed and the procedure is done where an external fixator is applied and the fracture is reduced in a closed manner.
An external fixator for distal radius fracture is an example of this surgery. Ilizarov’s external fixator application to fractures is also an example of this procedure.
Open Fracture Reduction and External Fixation
This option may be used in many cases. The typical indication is an open injury. Another indication is skin cover in a fracture resulting from injury or debridement.
Often the external fixation is used as a step-gap arrangement [ for example in ICU patients] till the time definitive surgery could be done.
