Fracture & Dislocation Manipulation — Principles

Indications for ED manipulation

• Neurovascular compromise distal to a fracture or dislocation — reduction should not wait for imaging if the limb/digit is threatened.
• Threatened skin — marked tenting or blanching over a displaced fragment, at risk of converting a closed injury to an open one.
• Gross deformity causing severe pain or preventing safe splinting/transfer.
• Joint dislocation (e.g. shoulder, elbow, ankle, finger) — most benefit from prompt reduction to relieve pain and reduce the risk of further neurovascular or cartilage injury.

Pre-reduction assessment

Analgesia ladder

• Entonox (50% nitrous oxide/oxygen) — quick-onset, short-acting, useful for brief manipulations and while other analgesia takes effect.
• IV analgesia — titrated opioid (e.g. morphine or fentanyl) alongside paracetamol; the mainstay for most reductions.
• Regional nerve blocks — e.g. femoral nerve block for neck-of-femur fractures, ring blocks for digits — excellent targeted analgesia with fewer systemic effects.
• Haematoma block — local anaesthetic injected directly into the fracture haematoma (classically distal radius); a reasonable, cost-effective alternative to procedural sedation for suitable fractures.
• Procedural sedation — for reductions needing deeper analgesia/muscle relaxation (e.g. shoulder or hip dislocation), following the RCEM Best Practice Guideline on Procedural Sedation with appropriate monitoring, fasting considerations, and a dedicated airway-competent clinician.

Equipment

Reduction principles

Most closed reductions follow the same generic biomechanical pattern, regardless of the specific joint or bone involved.

1. Traction and counter-traction

   Apply steady, sustained longitudinal traction distal to the fracture/dislocation, with an assistant providing counter-traction proximally, to disimpact overriding fragments.

2. Exaggerate, then reverse the deformity

   Where relevant (particularly angulated fractures), gently exaggerate the existing deformity first to unlock impacted fragments, then reverse through the neutral position to restore alignment.

3. Reassess reduction

   Check for restored contour, length and alignment clinically; a palpable/visible "clunk" or return of normal contour often signals successful reduction of a dislocation.

4. Immobilise in the reduced position

   Splint or cast promptly to maintain reduction, in a position of function/stability appropriate to the injury, avoiding excessive tightness that could compromise the just-restored circulation.

After reduction

1. Repeat neurovascular examination

   Re-check pulses, capillary refill, sensation and motor function immediately after reduction and again after splinting — splints themselves can cause new compromise.

2. Post-reduction imaging

   Confirm adequacy of reduction and rule out new complications (e.g. peri-articular fracture after dislocation reduction).

3. Analgesia and safety-netting

   Ensure ongoing analgesia is prescribed; give clear written advice on splint care, elevation, and red-flag symptoms of compartment syndrome or neurovascular compromise.

4. Definitive follow-up

   Refer to orthopaedics/fracture clinic as appropriate to the injury; some reductions (e.g. unstable fractures) need admission for definitive fixation.

Open fractures

Open fractures need a specific, time-critical pathway, per NICE NG37 and the BOA/BAPRAS Standards for the Management of Open Fractures (2020).

• IV antibiotics as soon as possible, ideally within 1 hour of injury — do not wait for surgical review to prescribe them.
• Photograph the wound at first assessment, then cover with a saline-soaked gauze dressing and avoid repeated wound exposure/inspection thereafter — this reduces infection risk and the number of times the wound is disturbed.
• Realign grossly deformed limbs and splint, checking neurovascular status before and after.
• Document tetanus status and give tetanus prophylaxis according to immunisation history and wound contamination.
• Debridement timing is guided by contamination and energy of injury — highly contaminated wounds need immediate debridement; theatre timing for others is agreed with the orthoplastic/orthopaedic team rather than dictated by a single fixed "6-hour rule".

Documentation

• Mechanism of injury, neurovascular exam before and after reduction, analgesia/sedation used.
• Method of reduction, number of attempts, any complications.
• Post-reduction imaging findings and adequacy of reduction.
• For open fractures: time of antibiotics, photograph taken, tetanus status, wound description before dressing.
• Safety-netting advice given and follow-up arranged.

Pitfalls & pearls

• Skipping the pre-reduction neurovascular exam is the commonest documentation failure identified in complaints and litigation — do it and write it down every time.
• Under-anaesthetising before reduction leads to muscle guarding, more attempts, and a worse experience for the patient — err towards more analgesia, not less.
• A splint applied too tightly after reduction can cause the very neurovascular compromise you just relieved — recheck after splinting, not just after reduction.
• Open fracture antibiotics should not wait for the orthopaedic team to see the patient — prescribe and give them yourself if there will be any delay.
• One clear photograph beats repeated wound exposure — minimise handling of open wounds.

References