Table of Contents IntroductionGeneral procedural detailPositioning and exposureEnsure analgesia or sedation is appropriateManipulationCleaningSome specific manipulation techniques Colles’ fractureAnkle fracturesDisplaced metacarpal fracture/fracture-dislocationLong bone fractures with neurovascular compromise Sedation/analgesia options Sedation – better for younger patients Entonox gas – good for all patientsLocal nerve blocks – very effective if appropriate block can be performed, especially good in elderly Introduction Wash hands, Introduce self, Patients name & DOB & wrist band, Explain procedure and get consentEnsure plaster technician is available with plaster trolley, and assistant for counter traction if requiredConfirm the correct site with the patient and X-rayPlan reduction technique using X-rayCheck and document distal neurovascular status before and after manipulation (note: reduce urgently if there is neurovascular compromise)Get an X-ray before and after manipulation General procedural detail Positioning and exposure Expose the sitePosition patientApply sheets to prevent plaster getting on bed/patient’s clothes Ensure analgesia or sedation is appropriate Test sensation/pain Manipulation Check plaster technician is ready and ask them to apply stockinette ± webrilManipulate fracture (specific details below)Ask assistant to apply plaster while holding limb in correct position until plaster driesAsk assistant to apply outer bandage layer when almost dry Cleaning Clean area and bin wasteCheck neurovascular statusOrder post-manipulation X-rayGive patient cast advice and book them fracture clinic appointment Some specific manipulation techniques May be used for common displaced fractures suitable for closed reduction. Colles’ fracture Usually use haematoma block ± Entonox for analgesiaAn extra assistant is required and must apply firm counter traction to upper forearm near elbowHolding both hands around fracture site with your thumbs on the top of their arm (proximal to fracture site) and fingers below (distal to fracture site):Exaggerate angulation deformity (by dorsally angulating fracture even more, i.e. pull hand upwards a lot!) to disimpact fractureLengthen by pulling on their hand (requires very firm traction for a few minutes)Firmly apply volar angulation to the fracture site (almost like breaking the fracture again in the opposite direction) and flex their wristUlna deviate their wrist by pulling thumb in line with forearmHold their wrist firmly in flexion and ulnar deviation while backslab is appliedAssistant to apply below elbow backslab (Colles’ position) Ankle fractures Bimalleolar and trimalleolar fractures will usually require fixation but often require manipulation while awaiting swelling to resolve before surgery. Usually require sedationPatient’s knee flexed over examination table (or them lying in bed if more practical)Ask assistant to apply stockinette and webrilReducing ankle fracture-dislocationGrasping their hindfoot, apply traction as if you are ‘taking their shoes off’, in order:Correct posterior subluxation by lifting heel anteriorlyCorrect external rotationCorrect ab/adductionRepositioning ankle fracture which is not dislocatedAsk assistant to apply plaster first (wet)Much less pressure is required – just move the ankle joint into the correct place while plaster dries as belowEnsure the ankle is held in the correct position – note it is a very unstable fracture and will fall out of place with gravity if not supported properlyEnsure ab/adduction is correct (i.e. ankle is in line with lower leg)Ensure posterior subluxation is correct (hold ball of foot anteriorly or hold foot up with great toe to ensure heel is in line with back of shin and ankle is at 90˚)Tweak the external rotation of ankle to match other side (look at position of the toe in line with the knee)Hold in place while below knee backslab is applied Displaced metacarpal fracture/fracture-dislocation Usually use Entonox ± morphine for analgesiaApply firm pressure over side of fracture to press back into positionApply dorsal/volar forearm slab or radial/ulnar gutter splint Long bone fractures with neurovascular compromise Analgesia options include morphine, local nerve blocks, Entonox, sedationNeurovascular compromise means they need to be done urgently before theatreApply longitudinal in-line traction to reposition boneUse skin/skeletal traction to maintain alignment if possible Learn more here…There’s more learning on fracture management here!